Invoice Orthodontist in United Arab Emirates Abu Dhabi –Free Word Template Download with AI
License No: DHA-ORTH-2023-4567
Department of Health - Abu Dhabi Approved Facility
Address: Al Reem Island, Tower 3, Level 5, Abu Dhabi, United Arab Emirates
Phone: +971 2 555 1234 | Email: [email protected]
VAT Registration: AE-123456789012345
Invoice Number: INV-2024-0892
Date of Issue: October 15, 2024
Due Date: November 15, 2024
Payment Terms: Net 30 Days
Bill To:
Patient Name: Ahmed Mohammed Al Mansouri
Emirates ID: 784-1990-1234567-8
Address: Yas Island, Sector 1, Villa 45, Abu Dhabi, United Arab Emirates
Phone: +971 50 123 4567
Email: [email protected]
Insurance Provider: Daman Insurance (Policy: DAM-2024-78901)
| # | Description of Orthodontic Services | Date | Qty | Unit Price (AED) | Amount (AED) | VAT (5%) |
|---|---|---|---|---|---|---|
| 1 | Initial Orthodontic Consultation and Comprehensive Examination including panoramic X-rays and digital impressions | 2024-09-01 | 1 | 350.00 | 350.00 | 17.50 |
| 2 | Custom Fabrication of Clear Aligner System (Invisalign®) - Full Treatment Plan for 24 aligners | 2024-09-15 | 1 | 12,500.00 | 12,500.00 | 625.00 |
| 3 | Professional Teeth Cleaning and Prophylaxis prior to aligner placement | 2024-09-15 | 1 | 250.00 | 250.00 | 12.50 |
| 4 | Monthly Orthodontic Adjustment and Progress Monitoring Visit | 2024-10-01 | 1 | 200.00 | 200.00 | 10.00 |
| 5 | Replacement of Lost Aligner Tray (Tray #8) | 2024-10-10 | 1 | 300.00 | 300.00 | 15.00 |
| 6 | Orthodontic Retainer Fabrication (Upper and Lower) - Post-Treatment Phase | 2024-10-15 | 1 | 800.00 | 800.00 | 40.00 |
| Subtotal: | AED 14,400.00 |
| Total VAT (5%): | AED 720.00 |
| Insurance Coverage (Daman): | -AED 3,000.00 |
| Grand Total Due: | AED 12,120.00 |
Important Notes and Terms:
1. This invoice is issued in accordance with the Federal Tax Authority regulations of the United Arab Emirates. All prices are quoted in United Arab Emirates Dirhams (AED).
2. Value Added Tax (VAT) at 5% is applied as per UAE Federal Decree-Law No. 8 of 2017 on Value Added Tax.
3. Payment is due within 30 days from the date of invoice. Late payments may incur a 2% monthly interest charge.
4. Insurance claims have been processed directly with Daman Insurance. The patient is responsible for any co-payment or non-covered services as outlined in their policy.
5. All orthodontic treatments are performed by licensed orthodontists registered with the Department of Health - Abu Dhabi (DOH).
6. Please retain this invoice for your records and for any insurance reimbursement purposes.
7. For payment inquiries, please contact our billing department at +971 2 555 1234 or email [email protected].
8. Accepted payment methods: Bank Transfer, Credit Card (Visa/Mastercard), Debit Card, and Cash.
9. Bank Transfer Details: Emirates NBD, Account Name: Abu Dhabi Orthodontic Excellence LLC, Account Number: 1001234567890, IBAN: AE070331234567890123456.
Authorized By:
Dr. Sarah Al HashimiLead Orthodontist
License: DHA-DOC-2023-1122
Received By:
Patient SignatureDate: _______________ ⬇️ Download as DOCX Edit online as DOCX
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