Invoice Orthodontist in Uganda Kampala –Free Word Template Download with AI
Specialist Orthodontist Services in Uganda
Plot 45, Kololo Hill Drive
Kampala, Uganda
Tel: +256 414 123 456 | Email: [email protected]
Reg No: URA-2023-889900
Invoice Number: INV-UG-2024-0892
Date of Issue: October 24, 2024
Due Date: November 07, 2024
Payment Status: Pending
Bill To:
Patient Name: Sarah Nakato
Guardian/Payer: Mr. James Nakato
Address: House No. 12, Bukoto Street, Kampala, Uganda
Phone: +256 772 998 877
Email: [email protected]
Patient ID: KPO-PT-4451
This invoice serves as an official request for payment for professional orthodontic services rendered at our clinic in Kampala, Uganda. As a leading provider of dental alignment and jaw correction services in the region, we are committed to delivering high-quality care. The charges listed below reflect the comprehensive treatment plan agreed upon during the initial consultation, covering diagnostic assessments, appliance fabrication, and clinical adjustments necessary for the patient's orthodontic progress.
| # | Description of Orthodontic Services | Quantity | Unit Price (UGX) | Total (UGX) |
|---|---|---|---|---|
| 1 |
Initial Comprehensive Orthodontic Consultation Includes clinical examination, discussion of treatment options, and preliminary diagnosis. |
1 | 150,000 | 150,000 |
| 2 |
Diagnostic Imaging and Records Panoramic X-ray, Cephalometric X-ray, and digital intraoral photography required for treatment planning in Uganda. |
1 | 350,000 | 350,000 |
| 3 |
Custom Orthodontic Impressions Taking of dental molds for the fabrication of study models and appliance setup. |
1 | 100,000 | 100,000 |
| 4 |
Placement of Fixed Metal Brackets (Full Arch) Bonding of brackets and archwires to upper and lower teeth. Includes all necessary bonding agents and materials. |
1 | 2,500,000 | 2,500,000 |
| 5 |
Monthly Adjustment and Monitoring Routine check-up to adjust wires, change ligatures, and monitor tooth movement. (Billed for October 2024). |
1 | 150,000 | 150,000 |
| 6 |
Emergency Repair Service Re-bonding of a loose bracket on the lower left canine due to accidental trauma. |
1 | 75,000 | 75,000 |
| 7 |
Orthodontic Elastics and Accessories Supply of rubber bands and interarch elastics for bite correction. |
3 | 25,000 | 75,000 |
Amount in words: Four Million, Twelve Thousand Uganda Shillings Only.
Payment Instructions & Terms
Bank Transfer:
Bank: Stanbic Bank Uganda Ltd
Branch: Kampala Road
Account Name: Kampala Premier Orthodontics Ltd
Account Number: 100234567890
Sort Code: 083
Please use Invoice Number INV-UG-2024-0892 as the payment reference.
Mobile Money:
MTN MoMo: +256 700 123 456
Airtel Money: +256 780 987 654
Payment is due within 14 days of the invoice date. Late payments may incur a penalty of 2% per month. Please ensure all payments are made in Uganda Shillings (UGX). If you have any questions regarding this invoice or your orthodontic treatment plan, please contact our billing department immediately.
Authorized Signature
Dr. Emily Kato
Lead Orthodontist
Patient/Guardian Acknowledgement
James Nakato
Date: _______________
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