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Dental Receipt
A dental receipt shows proof of payment for dental services such as cleanings, exams, or procedures. It is commonly used for dental insurance claims and FSA reimbursements.
Dental receipts usually include procedure codes, tooth references, and total paid.
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Header
94
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Date & Time
Items list
Quantity
Item
Total price
Title
Value
Payment
Title
Value
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DENTAL RECEIPT
Provider:
BrightSmile Dental Clinic
Phone: (312) 555-0122
Patient: Noah Carter
02/14/2026, 17:29:29
D0150 Comprehensive Oral Exam
$45.00
D1110 Prophylaxis (Adult Cleaning)
$70.00
D1206 Fluoride Varnish
$25.00
Tooth Ref: #14 (Noted)
$0.00
TOTALS
$140.00
Method
Card
Refge
33490188012A
Status
APPROVED
Receipt ID: DEN-20260214-0140
For dental insurance / FSA reimbursement.