Invoice Surgeon in Chile Santiago –Free Word Template Download with AI
Av. Providencia 1234, Oficina 501
Providencia, Santiago, Chile
RUT: 76.543.210-K
Tel: +56 2 2345 6789
Email: [email protected]
Invoice Number: INV-2023-8942
Date of Issue: October 24, 2023
Due Date: November 24, 2023
Service Date: October 20, 2023
Bill To
Mr. Roberto Valenzuela Soto
Av. Apoquindo 4500, Depto 12B
Las Condes, Santiago, Chile
RUT: 15.678.901-2
Email: [email protected]
Patient Details
Name: Roberto Valenzuela Soto
Date of Birth: March 15, 1978
Insurance Provider: Isapre Colmena
Policy Number: ISAP-99887766
Attending Surgeon: Dr. Alejandro Fuentes
| # | Description of Surgical Services | Quantity | Unit Price (CLP) | Total (CLP) |
|---|---|---|---|---|
| 1 |
Professional Surgeon Fee - Arthroscopic Knee Surgery Includes pre-operative consultation, surgical intervention by Dr. Alejandro Fuentes (Specialist in Orthopedic Surgery), and immediate post-operative assessment. Procedure performed at Centro Quirúrgico Metropolitano, Santiago. |
1 | $1.250.000 | $1.250.000 |
| 2 |
Anesthesiologist Services General anesthesia administration and monitoring during the surgical procedure. Includes pre-anesthesia evaluation and post-anesthesia care unit (PACU) monitoring for 2 hours. |
1 | $450.000 | $450.000 |
| 3 |
Operating Room Facility Fee Use of surgical suite, nursing staff, and standard surgical instruments for a duration of 3 hours. Includes sterilization and maintenance costs compliant with Chilean health regulations. |
1 | $680.000 | $680.000 |
| 4 |
Medical Implants and Consumables Includes arthroscopic cannulas, suture materials, hemostatic agents, and specialized knee repair devices. All materials are certified for medical use in Chile. |
1 | $320.000 | $320.000 |
| 5 |
Post-Operative Follow-Up Consultation Scheduled review appointment with the Surgeon 7 days post-surgery to assess wound healing and initial recovery progress. Includes prescription management. |
1 | $150.000 | $150.000 |
| 6 |
Diagnostic Imaging (Pre-Op MRI) Magnetic Resonance Imaging of the right knee performed prior to surgery to determine surgical approach. Radiology report included. |
1 | $280.000 | $280.000 |
| Subtotal: | $3.130.000 |
| IVA (19% Tax): | $594.700 |
| Total Amount Due: | $3.724.700 CLP |
Payment Instructions
Please remit payment within 30 days of the invoice date. Payments can be made via bank transfer to the following account:
Bank: Banco de Chile
Account Name: Centro Quirúrgico Metropolitano SpA
Account Number: 1234567890123
CLABE: 7190123456789012345678
Please reference Invoice Number INV-2023-8942 in the transfer description. For insurance claims, please submit this invoice along with the medical report to your provider.
Important Notes
This invoice represents the professional and facility fees for the surgical services rendered by Dr. Alejandro Fuentes in Santiago, Chile. The Surgeon has performed all duties in accordance with the standards of the Chilean Medical College. Any additional complications or extended hospital stays not covered in this invoice will be billed separately.
If you have any questions regarding this invoice or the services provided, please contact our billing department at +56 2 2345 6789 or email [email protected].
Authorized Signature
Dr. Alejandro Fuentes
Lead Surgeon
Received By
__________________________
Date: ____________________
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