Invoice Psychiatrist in Bangladesh Dhaka –Free Word Template Download with AI
Senior Consultant Psychiatrist
Green Road Medical Complex, House #12, Road #5
Banani, Dhaka-1213, Bangladesh
Phone: +880 1712-345678 | Email: [email protected]
Invoice #: INV-DHA-2023-0892
Date: October 24, 2023
Due Date: November 07, 2023
Service Provider
Dr. Farhana Rahman
Registered with Bangladesh Medical & Dental Council (BMDC)
Reg. No: BMDC-456789
VAT/TIN: 123456789012
Bill To
Mr. Rafiqul Islam
Flat #304, Gulshan Avenue Tower
Gulshan-2, Dhaka-1212, Bangladesh
Phone: +880 1812-987654
Email: [email protected]
| Description of Services | Date of Service | Quantity | Unit Price (BDT) | Total (BDT) |
|---|---|---|---|---|
|
Initial Psychiatric Consultation & Assessment Comprehensive evaluation including clinical interview, mental status examination, and diagnostic formulation for anxiety and depressive disorders. Includes review of medical history and current medication regimen. |
Oct 10, 2023 | 1 | 3,500.00 | 3,500.00 |
|
Follow-up Psychiatric Session Monitoring of treatment progress, adjustment of pharmacotherapy, and supportive psychotherapy. Discussion of side effects and adherence to prescribed regimen. |
Oct 17, 2023 | 1 | 2,500.00 | 2,500.00 |
|
Psychological Testing & Interpretation Administration and scoring of standardized psychological assessments (Beck Depression Inventory-II, GAD-7, and MMPI-2). Detailed written report provided to patient and referring physician if applicable. |
Oct 12, 2023 | 1 | 5,000.00 | 5,000.00 |
|
Prescription & Medication Management Detailed prescription for psychotropic medications including SSRIs and anxiolytics. Includes counseling on proper usage, potential interactions, and expected timeline for therapeutic effects. |
Oct 10, 2023 | 1 | 500.00 | 500.00 |
|
Emergency Teleconsultation Urgent remote consultation via secure video call for acute symptom exacerbation. Provided immediate crisis intervention and safety planning. |
Oct 20, 2023 | 1 | 2,000.00 | 2,000.00 |
Important Notes & Terms:
- All services rendered are in accordance with the standards set by the Bangladesh Medical & Dental Council (BMDC) and the Bangladesh Psychiatric Association.
- This invoice is valid for payment within 14 days from the date of issue. Late payments may incur a 2% monthly interest charge.
- Confidentiality of all medical information is maintained as per the Data Protection Act of Bangladesh and international medical ethics.
- Insurance claims: Please submit this invoice along with the detailed medical report to your insurance provider for reimbursement. We accept direct billing from major insurance companies operating in Dhaka.
- For any discrepancies or questions regarding this invoice, please contact our office during business hours (Saturday to Thursday, 10:00 AM - 7:00 PM).
Payment Methods Accepted in Dhaka:
Bank Transfer:
Bank: BRAC Bank PLC
Branch: Banani, Dhaka
Account Name: Dr. Farhana Rahman
Account Number: 1234-5678-9012-3456
Routing Code: BRAC0000012
Digital Payment:
bKash: 01712345678 (Merchant)
Nagad: 01812345678 (Merchant)
Rocket: 01912345678 (Merchant)
Cash: Accepted at clinic during consultation hours.
Authorized Signature
Dr. Farhana Rahman
Consultant Psychiatrist
Patient Acknowledgment
Signature: ___________________
Date: ___________________
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