Invoice Orthodontist in Vietnam Ho Chi Minh City –Free Word Template Download with AI
Specialized Dental & Orthodontic Center
123 Nguyen Hue Boulevard, District 1
Ho Chi Minh City, Vietnam
Tax Code: 0312345678
Phone: +84 28 3822 1234 | Email: [email protected]
Billed To (Patient/Guarantor)
Name: Nguyen Van Minh
Address: 45 Le Loi Street, District 3
City: Ho Chi Minh City, Vietnam
Phone: +84 90 123 4567
Email: [email protected]
Patient ID: PAT-88291
Insurance / Third Party Payer
Provider: PVI Health Insurance
Policy Number: PVI-2023-XYZ-998
Group Number: GRP-CORP-55
Authorization Code: AUTH-7721
Referring Orthodontist: Dr. Tran Thi Lan
| # | Description of Orthodontic Services | Code | Qty | Unit Price (VND) | Total (VND) |
|---|---|---|---|---|---|
| 1 |
Comprehensive Orthodontic Consultation & Diagnostic Records Includes panoramic X-ray, cephalometric analysis, intraoral photography, and digital smile design assessment performed at our Ho Chi Minh City clinic. |
D0150 | 1 | 1,500,000 | 1,500,000 |
| 2 |
Initial Placement of Self-Ligating Brackets (Full Arch) Application of premium ceramic self-ligating brackets for superior aesthetics and comfort. Includes bonding agent and isolation materials. |
D8050 | 1 | 12,000,000 | 12,000,000 |
| 3 |
Custom Archwire Fabrication & Adjustment NiTi (Nickel-Titanium) initial archwire placement to begin alignment phase. |
D8060 | 1 | 2,500,000 | 2,500,000 |
| 4 |
Interproximal Reduction (IPR) Minimal enamel stripping to create space for alignment, performed under local anesthesia. |
D4341 | 1 | 1,200,000 | 1,200,000 |
| 5 |
Orthodontic Elastics & Accessories Kit Provision of monthly supply of elastics, wax, and cleaning tools for home care. |
D8070 | 3 | 350,000 | 1,050,000 |
| 6 |
Emergency Orthodontic Adjustment Repair of loose bracket and wire trimming due to trauma. |
D8080 | 1 | 800,000 | 800,000 |
Amount in words: Fifteen million, four hundred fifty-five thousand Vietnamese Dong only.
Payment Terms & Important Information
This invoice is issued by Saigon Elite Orthodontics, a licensed dental practice operating in Ho Chi Minh City, Vietnam. Payment is due within 14 days of the invoice date. Late payments may incur a penalty fee of 2% per month.
Bank Transfer Details:
Bank: Vietcombank - District 1 Branch
Account Name: Saigon Elite Orthodontics Co., Ltd.
Account Number: 0071001234567
SWIFT Code: BFTVVNVX
Reference: Please include Invoice Number INV-2023-10-089
Clinic Policy: All orthodontic treatments are customized. The services listed above reflect the specific care plan agreed upon during the consultation. Regular follow-up appointments are mandatory to ensure the success of the orthodontic treatment. Failure to attend scheduled appointments may result in additional fees or discontinuation of treatment.
Legal Notice: This document serves as an official tax invoice in accordance with the regulations of the Ministry of Finance of Vietnam. Please retain this document for your records and insurance claims.
Authorized By:
Dr. Tran Thi LanLead Orthodontist
Saigon Elite Orthodontics
Patient Acknowledgement:
Signature & DateNguyen Van Minh ⬇️ Download as DOCX Edit online as DOCX
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