Quotation Estimate Dentist in Belgium Brussels –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Quotation No.: QTE-2025-04871

Date of Issue: 15 June 2025

Valid Until: 15 July 2025

Currency: EUR (€)

Prepared By: Dr. Annelise Vermeulen, DDS

Client Information

Name: Mr. James Anderson

Address: 45 Avenue Louise, 1050 Brussels, Belgium

Phone: +32 470 123 456

Email: [email protected]

RIZIV/INAMI No.: 85.12.34.56.789

Dear Mr. Anderson,

Thank you for choosing Brussels Dental Care Centre for your dental health needs. Following your comprehensive consultation and diagnostic examination conducted on 10 June 2025, we are pleased to present this Quotation Estimate detailing the full scope of recommended dental treatments. As a licensed Dentist practice operating in Belgium Brussels, we are committed to providing transparent, high-quality care in full compliance with Belgian healthcare regulations and the standards set by the Belgian Order of Dentists.

Scope of Treatment – Itemised Quotation Estimate

Ref.	Dental Procedure	Description	Qty	Unit Price (€)	Total (€)
01	Full Oral Examination & Digital X-Rays	Comprehensive intraoral examination, panoramic radiograph (OPG), and four periapical digital X-rays for baseline documentation.	1	120.00	120.00
02	Professional Dental Hygiene & Scaling	Ultrasonic scaling, air-polishing, and fluoride application. Includes periodontal charting and gum health assessment.	1	185.00	185.00
03	Composite Resin Fillings (Teeth #14, #24)	Removal of carious tissue and restoration with aesthetic composite resin material. Two separate restorations on upper premolars.	2	210.00	420.00
04	Root Canal Treatment (Tooth #36)	Endodontic treatment of the lower left molar including access cavity preparation, canal instrumentation, obturation, and temporary restoration. Follow-up permanent crown required.	1	650.00	650.00
05	Ceramic Crown (Tooth #36)	Full zirconia ceramic crown to restore structural integrity following root canal treatment. Includes impression, try-in, and final cementation.	1	890.00	890.00
06	Extraction of Tooth #18 (Wisdom Tooth)	Surgical extraction of the upper right third molar under local anaesthesia. Includes pre-operative radiographic assessment and post-operative instructions.	1	320.00	320.00
07	Follow-Up Visits & Adjustments	Two scheduled post-treatment review appointments at 2 weeks and 6 weeks to monitor healing, verify occlusion, and make any necessary adjustments.	2	45.00	90.00
Subtotal (before RIZIV/INAMI reimbursement)					2,675.00
Estimated RIZIV/INAMI Reimbursement (approx. 65%)					-1,738.75
Estimated Patient Out-of-Pocket Cost					936.25

Important Note: The RIZIV/INAMI reimbursement amounts listed above are estimates based on the current Belgian national tariff grid (barème national). Actual reimbursement may vary depending on your specific mutualité (mutual insurance) supplementary coverage. We strongly recommend verifying your supplementary dental benefits with your mutualité prior to commencing treatment. This Quotation Estimate does not constitute a binding invoice; final billing will reflect any clinical adjustments made during treatment. Terms and Conditions of This Quotation Estimate

Validity: This Quotation Estimate is valid for 30 calendar days from the date of issue. After this period, prices may be subject to revision in accordance with the Belgian healthcare fee schedule updates.
Payment Terms: A deposit of 30% of the total estimated cost is required to schedule the first treatment appointment. The remaining balance is due upon completion of each treatment phase. Payment may be made by bank transfer, credit card, or cash at our practice in Brussels.
Insurance & Reimbursement: As a registered Dentist in Belgium Brussels, we are contracted with RIZIV/INAMI. We will submit all eligible claims directly to your mutualité on your behalf. Supplementary coverage (supplémentaire) will be processed separately by your mutual insurance provider.
Cancellations & Rescheduling: Appointments must be cancelled or rescheduled at least 48 hours in advance. Late cancellations or no-shows will incur a fee of 50% of the scheduled procedure cost.
Clinical Adjustments: Should the Dentist identify additional or unforeseen clinical requirements during treatment (e.g., additional caries, periodontal complications), a revised Quotation Estimate will be provided and your written consent obtained before any additional work is performed.
Warranty: All restorative work (fillings, crowns) carries a 2-year warranty against material defects, provided the patient adheres to the recommended maintenance schedule of at least one professional hygiene visit per year at our Brussels practice.
Confidentiality: All patient records and clinical data are handled in strict accordance with the Belgian Privacy Act (Loi du 30 juillet 2018) and the EU General Data Protection Regulation (GDPR).
Dispute Resolution: Any disputes arising from this Quotation Estimate or the services rendered shall be resolved in accordance with Belgian law, under the jurisdiction of the courts of Brussels.

Acceptance

By signing below, the client acknowledges receipt of this Quotation Estimate and agrees to the terms and conditions outlined above. This signature does not constitute a binding commitment to proceed with all listed treatments; the client may elect to proceed with any subset of the recommended procedures.

Client Signature

Name: ___________________________

Signature: ___________________________

Date: ___________________________

Practice Representative

Name: Dr. Annelise Vermeulen, DDS

Signature: ___________________________

Date: ___________________________

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