Invoice Radiologist in Sri Lanka Colombo –Free Word Template Download with AI
No. 45, Galle Road, Colombo 03, Sri Lanka
Tel: +94 11 234 5678 | Email: [email protected]
Reg No: C/12345 | VAT No: 123456789V
Lead Radiologist: Dr. A. Perera, MBBS, MRCP (UK), FRCR
Invoice Number: INV-2023-0892
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Service Period: October 2023
Bill To:
HealthGuard Insurance Lanka Ltd.
Att: Claims Department
Level 12, World Trade Centre
Colombo 01, Sri Lanka
Policy Holder: Mr. K. Silva
Policy Number: HG-998877
Patient Details:
Name: Mr. K. Silva
NIC: 1985XXXXXV
Address: 12, Lake House Road, Colombo 07
Referring Physician: Dr. S. Fernando
| # | Description of Radiological Services | Quantity | Unit Price (LKR) | Total (LKR) |
|---|---|---|---|---|
| 1 |
Consultation with Senior Radiologist Comprehensive review of clinical history and preliminary imaging assessment by a certified Radiologist in Colombo. Includes detailed discussion of findings with the referring physician. |
1 | 5,000.00 | 5,000.00 |
| 2 |
MRI Scan - Lumbar Spine (Without Contrast) High-resolution Magnetic Resonance Imaging performed on a 1.5 Tesla scanner. Includes multi-planar imaging and detailed interpretation report by the Radiologist. |
1 | 25,000.00 | 25,000.00 |
| 3 |
CT Scan - Chest with Contrast Computed Tomography of the thorax using iodinated contrast media. Includes pre-scan assessment, administration of contrast, and post-scan monitoring. Detailed radiological report included. |
1 | 18,500.00 | 18,500.00 |
| 4 |
Digital X-Ray - Chest (PA & Lateral) Standard diagnostic radiography. Includes image processing and interpretation by the Radiologist. |
1 | 2,500.00 | 2,500.00 |
| 5 |
Ultrasound - Abdomen (Complete) Real-time sonographic examination of abdominal organs. Includes Doppler assessment if clinically indicated. Report issued by the Radiologist. |
1 | 6,000.00 | 6,000.00 |
| 6 |
Contrast Media & Consumables Cost of iodinated contrast agent, IV cannula, and other necessary medical supplies used during the CT procedure. |
1 | 3,000.00 | 3,000.00 |
| 7 |
CD/DVD of Digital Images (DICOM Format) Physical copy of all radiological images for transfer to the referring physician or for second opinion. |
1 | 500.00 | 500.00 |
Payment Terms & Notes:
Payment Method: Payment is expected via bank transfer to the account details below or by cheque payable to "Colombo Advanced Imaging & Radiology Centre".
Bank Details:
Bank: Commercial Bank of Ceylon
Branch: Colombo Fort
Account Name: Colombo Advanced Imaging & Radiology Centre (Pvt) Ltd
Account Number: 1234-5678-9012-3456
Important: This invoice represents professional services rendered by a qualified Radiologist in Sri Lanka Colombo. All interpretations are based on the images acquired at the time of examination. If you have any questions regarding this invoice or the radiological reports, please contact our billing department immediately. Late payments may incur a penalty fee of 1.5% per month.
Validity: This invoice is valid for 30 days from the date of issue. Please quote the Invoice Number (INV-2023-0892) in all correspondence and payments.
Authorized Signature
Finance Manager
Radiologist's Verification
Dr. A. Perera, FRCR
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