Quotation Estimate Dentist in Canada Montreal –Free Word Template Download with AI
4520 Rue Saint-Denis, Suite 300, Montreal, Quebec, Canada H2J 2K5
Phone: (514) 555-0187 | Email: [email protected] | Reg. No. QDC-2019-44782
Quotation Estimate No.: QE-2025-00347 Date Issued: June 12, 2025 Valid Until: July 12, 2025 Prepared For: Mr. Jonathan Lavoie Patient ID: PT-88214 Address: 1287 Avenue du Mont-Royal, Montreal, QC, Canada H2G 1T41. Purpose of This Quotation Estimate
This Quotation Estimate has been prepared by the undersigned Dentist, Dr. Marie-Claire Tremblay, operating in compliance with the regulations of the Ordre des médecins dentistes du Québec (OMDQ) and the broader dental licensing standards of Canada. It provides Mr. Jonathan Lavoie with a detailed, itemized financial projection for the comprehensive dental treatment plan recommended following his clinical examination conducted on June 5, 2025, at our Montreal clinic. This document serves as a formal Quotation Estimate and does not constitute a binding invoice until the patient provides written authorization to proceed with the outlined procedures.
2. Clinical Summary and Recommended Treatment
Following a thorough diagnostic evaluation, including full-mouth periapical radiographs, intraoral digital imaging, and a periodontal charting assessment performed at our Montreal, Canada practice, the following dental interventions have been recommended to restore optimal oral health, function, and aesthetics for the patient. As your treating Dentist in Montreal, I have designed this treatment sequence to address both immediate concerns and long-term preventive care within the context of the Canadian healthcare framework.
3. Itemized Quotation Estimate – Services and Fees
| Item No. | Dental Procedure / Service | CDIP Code | Quantity | Unit Price (CAD) | Subtotal (CAD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Diagnostic Examination & Digital X-Rays (Full Series) | 01-100 | 1 | $185.00 | $185.00 |
| 2 | Prophylaxis – Adult (Scaling & Polishing, Upper and Lower) | 02-100 | 1 | $145.00 | $145.00 |
| 3 | Root Canal Therapy – Maxillary Molar (Tooth #3) | 05-100 | 1 | $1,250.00 | $1,250.00 |
| 4 | Porcelain Crown – Maxillary Molar (Tooth #3), including temporary crown | 06-100 | 1 | $1,480.00 | $1,480.00 |
| 5 | Composite Resin Restoration – Mandibular Premolar (Tooth #20) | 04-100 | 1 | $320.00 | $320.00 |
| 6 | Periodontal Deep Cleaning (Scaling & Root Planing) – 4 Quadrants | 02-200 | 4 | $210.00 | $840.00 |
| 7 | Full-Mouth Intraoral Digital Photography & Treatment Planning Session | 01-200 | 1 | $95.00 | $95.00 |
| 8 | Follow-Up Appointment – Post-Root Canal & Crown Seating (2 visits) | 01-300 | 2 | $85.00 | $170.00 |
| 9 | Fluoride Varnish Application & Oral Hygiene Instruction | 02-300 | 1 | $45.00 | $45.00 |
| Subtotal (Before Tax): | $4,530.00 | ||||
| QST (Quebec Sales Tax – 5%): | $226.50 | ||||
| GST (Goods & Services Tax – 5%): | $226.50 | ||||
| TOTAL ESTIMATED COST (CAD): | $4,983.00 | ||||
4. Insurance and Payment Information
Please note that this Quotation Estimate reflects the full fee schedule of our Montreal dental practice. As a licensed Dentist in Canada, I am registered with the Quebec Dental Insurance Plan (MDIC) and accept most major Canadian dental insurance providers, including Sun Life, Manulife, Desjardins, and Great-West Life. The patient is advised to submit this Quotation Estimate directly to their insurance carrier for pre-authorization and to confirm the applicable coverage percentage before commencing treatment. Any portion not covered by insurance will be the patient's responsibility. Payment plans and financing options through our Montreal office are available upon request for the total amount of this Quotation Estimate.
5. Terms and Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) days from the date of issuance. Fees are subject to revision after the expiration date due to potential changes in material costs, supply pricing, or regulatory adjustments within the Province of Quebec, Canada.
- All prices are quoted in Canadian Dollars (CAD) and are inclusive of standard materials. Premium or custom materials, if requested by the patient, may result in additional charges not reflected in this Quotation Estimate.
- The Dentist reserves the right to modify the treatment plan if clinical findings change during the course of procedures. Any such modifications will be communicated to the patient in writing prior to additional work, and a revised Quotation Estimate will be issued.
- A deposit of 30% of the total estimated amount is required to schedule the first treatment appointment. The remaining balance is due upon completion of each phase of treatment.
- This Quotation Estimate does not guarantee a specific clinical outcome. The Dentist will exercise all reasonable professional judgment consistent with the standards of practice in Montreal, Quebec, and Canada at large.
- Appointments must be cancelled or rescheduled with a minimum of 48 hours' notice. Late cancellations or no-shows may incur a fee of $100.00, as per the clinic's policy in Montreal.
- This document is governed by the laws of the Province of Quebec and the federal laws of Canada applicable to dental practice and consumer protection.
6. Patient Acknowledgment
By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the recommended dental treatment plan, and authorizes the Dentist to proceed with the outlined procedures at the Montreal, Canada clinic. The patient further confirms that they have had the opportunity to ask questions and have received satisfactory answers regarding the scope, risks, alternatives, and estimated costs associated with the proposed treatment.
Patient Signature: ______________________________Name: Jonathan Lavoie
Date: ______________________ Dentist / Authorized Representative: ______________________________
Dr. Marie-Claire Tremblay, DDS
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
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