Quotation Estimate Dentist in Australia Sydney –Free Word Template Download with AI
Professional Dental Services — Australia Sydney
Ref: QTE-SYD-2025-04871 | Date Issued: 15 June 2025 | Valid Until: 15 July 2025
AUSTRALIA SYDNEY — REGISTERED DENTAL PRACTICEDentist / Practice Details
Dr. Sarah Mitchell, BDS, MDS
Sydney Harbour Dental Centre
Level 4, 128 George Street
Sydney NSW 2000, Australia
ABN: 54 123 456 789
Phone: +61 2 9377 4521
Email: [email protected]
Client / Patient Details
Mr. James A. Thompson
47 Waverley Street
Paddington NSW 2021
Sydney, Australia
Phone: +61 412 556 789
Email: [email protected]
Health Fund: Bupa (Member #BP-8842190)
This Quotation Estimate has been prepared by our registered Dentist at Sydney Harbour Dental Centre, Australia Sydney, following a comprehensive clinical examination and diagnostic imaging conducted on 10 June 2025. The following line items represent the estimated costs for the proposed course of dental treatment. All pricing is in Australian Dollars (AUD) and reflects current fee schedules as registered with the Australian Dental Association (ADA) for the Australia Sydney metropolitan region.
| Item No. | Dental Procedure / Service | ADA Item Code | Qty | Unit Price (AUD) | Subtotal (AUD) |
|---|---|---|---|---|---|
| 01 | Comprehensive Oral Examination & Digital X-Ray (Full Mouth Series) | 101 | 1 | $185.00 | $185.00 |
| 02 | Ultrasonic Scaling & Polishing (Prophylaxis) — Upper & Lower Arch | 102 | 1 | $245.00 | $245.00 |
| 03 | Composite Resin Filling — Tooth #26 (Upper Left First Molar), 2 Surfaces | 103 | 1 | $320.00 | $320.00 |
| 04 | Root Canal Treatment (Endodontic Therapy) — Tooth #36 (Lower Left First Molar) | 104 | 1 | $1,150.00 | $1,150.00 |
| 05 | Ceramic Crown (Zirconia) — Tooth #36, Post-Endodontic Restoration | 105 | 1 | $1,480.00 | $1,480.00 |
| 06 | Extraction — Tooth #48 (Lower Right Third Molar / Wisdom Tooth), Surgical | 106 | 1 | $520.00 | $520.00 |
| 07 | Follow-Up Review & Suture Removal (2-week post-operative visit) | 107 | 1 | $95.00 | $95.00 |
| 08 | Local Anaesthetic & Sedation (Nitrous Oxide) — Per Procedure | 108 | 3 | $65.00 | $195.00 |
| 09 | Prescription Medication & Post-Operative Care Kit | 109 | 1 | $48.00 | $48.00 |
| TOTAL ESTIMATED COST (AUD) | $4,238.00 | ||||
| Estimated Health Fund Rebate (Bupa — subject to policy terms) | -$1,847.00 | ||||
| PATIENT OUT-OF-POCKET ESTIMATE (AUD) | $2,391.00 | ||||
This Quotation Estimate reflects the treatment plan recommended by your treating Dentist at our Australia Sydney practice. The root canal treatment and subsequent ceramic crown on tooth #36 are clinically necessary to preserve the natural tooth structure and prevent further infection. The surgical extraction of tooth #48 is advised due to pericoronitis and impaction, which, if left untreated, may compromise adjacent dentition. All procedures will be performed in accordance with the Australian Dental Association's Code of Ethics and the NSW Health regulations governing dental practice in Australia Sydney.
Please note that this Quotation Estimate is a good-faith estimate based on current clinical findings. Should additional pathology be discovered during the course of treatment (for example, an unexpected fracture or additional carious lesion), the Dentist will consult with you prior to proceeding with any additional work, and a revised Quotation Estimate will be issued at no additional cost.
Terms & Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, fees may be adjusted to reflect changes in the Australia Sydney dental fee schedule or material costs.
- All prices are quoted in Australian Dollars (AUD) and include GST (10%) as required by the Australian Taxation Office for registered dental practices in Australia Sydney.
- Payment is due at the time of service unless a written payment arrangement has been agreed upon in advance. We accept all major credit cards, EFT, and HICAPS direct health fund claiming.
- The estimated health fund rebate is indicative only and is subject to the terms, conditions, and annual limits of your specific Bupa dental policy. The Dentist and practice are not responsible for any discrepancy between the estimated and actual rebate.
- Appointments must be cancelled or rescheduled with a minimum of 24 hours' notice. Late cancellations or no-shows may incur a fee of $100.00 AUD as per Australia Sydney dental practice standards.
- This Quotation Estimate does not constitute a guarantee of clinical outcome. The Dentist will exercise all reasonable professional skill and care in accordance with the standard of practice expected of a competent dental practitioner in Australia Sydney.
- Warranty: All restorative work (crowns, fillings) carries a 12-month workmanship warranty from the date of placement, provided the patient attends all scheduled recall appointments.
Treating Dentist — Sydney Harbour Dental Centre
Australia Sydney, NSW 2000
Date: _______________ Mr. James A. Thompson
Patient / Client Acknowledgement
Australia Sydney, NSW 2021
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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