Invoice Orthodontist in Thailand Bangkok –Free Word Template Download with AI
123 Sukhumvit Road, Khlong Toei Nuea
Watthana District, Bangkok 10110, Thailand
Tax ID: 0105559000123
Phone: +66 2 123 4567 | Email: [email protected]
Official Tax Invoice
Bill To: Mr. James Anderson45/2 Wireless Road, Lumpini
Pathum Wan, Bangkok 10330
Thailand
Phone: +66 89 123 4567
Email: [email protected]
| # | Description of Orthodontic Services | Code | Unit Price (THB) | Total (THB) |
|---|---|---|---|---|
| 1 |
Initial Comprehensive Orthodontic Consultation Includes panoramic X-ray, cephalometric analysis, digital intraoral scanning, and treatment planning session with lead Orthodontist. |
CONS-01 | 2,500.00 | 2,500.00 |
| 2 |
Clear Aligner Therapy (Full Series) Custom-fabricated series of 28 clear aligners for upper and lower arches. Includes digital simulation of tooth movement. |
ALIGN-28 | 85,000.00 | 85,000.00 |
| 3 |
Interproximal Reduction (IPR) Minimal enamel stripping to create space for alignment. Performed under local anesthesia. |
PROC-IPR | 3,000.00 | 3,000.00 |
| 4 |
Monthly Monitoring Visits (12 Months) Regular check-ups to monitor progress, ensure aligner fit, and adjust treatment plan if necessary. |
VISIT-MON | 1,500.00 | 18,000.00 |
| 5 |
Retention Phase: Fixed Retainers Bonded wire retainers for lower anterior teeth to maintain alignment post-treatment. |
RET-FIX | 5,000.00 | 5,000.00 |
| 6 |
Retention Phase: Removable Essix Retainers Set of 3 clear removable retainers for upper and lower arches for nighttime wear. |
RET-ESS | 4,500.00 | 4,500.00 |
Important Notes & Payment Terms
This invoice represents the agreed-upon cost for orthodontic treatment provided by Bangkok Elite Orthodontics. All prices are quoted in Thai Baht (THB). Payment is due within 30 days of the invoice date. Late payments may incur a 1.5% monthly interest charge.
Payment Methods:
Bank Transfer: Bangkok Bank, Account Name: Bangkok Elite Orthodontics Co., Ltd., Account No: 123-4-56789-0
Credit Card: Visa, Mastercard, JCB accepted at clinic with 1% surcharge.
Please reference your Invoice Number (INV-BKK-2023-0892) when making payment.
Treatment Guarantee:
We stand behind the quality of our orthodontic care. In the event of relapse within 12 months of treatment completion, a complimentary adjustment consultation will be provided.
Retainers must be worn as prescribed to maintain results.
Privacy Policy:
Your personal and medical information is handled in accordance with Thailand's Personal Data Protection Act (PDPA).
Records will be retained for a minimum of 7 years as required by medical regulations.
Dr. Somchai Prasert, DDS, MSc Orthodontics Patient Acknowledgment
Signature indicates acceptance of terms and payment obligation ⬇️ Download as DOCX Edit online as DOCX
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