Quotation Estimate Dentist in Germany Berlin –Free Word Template Download with AI
Kastanienallee 47, 10435 Berlin, Germany | Tel: +49 30 4455 6677 | E-Mail: [email protected]
Quotation EstimateQuotation Details
Quotation No.: QTE-2025-04182
Date of Issue: 12 June 2025
Valid Until: 12 July 2025
Prepared By: Dr. Anke Hoffmann, DDS
Location: Berlin, Germany
Patient Information
Name: [Patient Full Name]
Address: [Street, Postal Code, City, Germany]
Date of Birth: [DD/MM/YYYY]
Insurance Provider: [e.g., AOK, TK, Barmer, or Private]
Insurance No.: [XXXXXXXXXX]
Phone: [XXXXXXXXXX]
This Quotation Estimate has been prepared by our dental practice in Berlin, Germany, following a comprehensive clinical examination and diagnostic imaging (intraoral radiographs and panoramic X-ray) conducted on 10 June 2025. The following Quotation Estimate outlines the anticipated dental procedures, associated materials, and professional fees required to address the identified oral health conditions. All pricing in this Quotation Estimate reflects the current fee schedule applicable to dental services in Berlin, Germany, and is subject to the German Dental Fee Schedule (Gebührenordnung für Zahnärzte – GOZ) for private patients or the statutory dental fee schedule (BEMA) for patients covered by the German public health insurance system (Gesetzliche Krankenversicherung).
| No. | Dental Procedure / Service | GOZ / BEMA Code | Qty | Unit Price (EUR) | Subtotal (EUR) |
|---|---|---|---|---|---|
| 1 | Comprehensive dental examination, diagnosis, and treatment planning (initial consultation in Berlin, Germany) | GOZ 1010 | 1 | € 45.00 | € 45.00 |
| 2 | Full-mouth digital panoramic radiograph (OPG) and 6 periapical intraoral X-rays | GOZ 1011 / 1012 | 1 | € 68.00 | € 68.00 |
| 3 | Ultrasonic scaling and professional dental prophylaxis (full arch, upper and lower) | GOZ 1020 / 1021 | 2 | € 52.00 | € 104.00 |
| 4 | Removal of dental caries and placement of composite resin restoration – tooth #16 (upper right first molar) | GOZ 2010 / 2011 | 1 | € 185.00 | € 185.00 |
| 5 | Root canal treatment (endodontic therapy) – tooth #24 (upper left first premolar), single canal | GOZ 2510 / 2511 / 2512 | 1 | € 320.00 | € 320.00 |
| 6 | Placement of a full ceramic (zirconia) crown – tooth #24, including temporary crown and final cementation | GOZ 2610 / 2611 / 2612 | 1 | € 520.00 | € 520.00 |
| 7 | Extraction of impacted third molar (wisdom tooth) – tooth #48, lower right, surgical removal under local anaesthesia | GOZ 3010 / 3011 | 1 | € 275.00 | € 275.00 |
| 8 | Post-operative follow-up visit and suture removal (week 1 and week 2 appointments in Berlin, Germany) | GOZ 3012 | 2 | € 35.00 | € 70.00 |
| 9 | Fluoride varnish application and personalised oral hygiene instruction | GOZ 1022 | 1 | € 28.00 | € 28.00 |
| 10 | Local anaesthetic (articaine 4%) and consumables (gloves, syringes, gauze, etc.) | GOZ 1000 | 1 | € 32.00 | € 32.00 |
| Subtotal (before VAT): | € 1,647.00 | ||||
| VAT (19% – Umsatzsteuer, Germany): | € 312.93 | ||||
| Total Quotation Estimate Amount: | € 1,959.93 | ||||
Note: For patients covered by the German statutory health insurance (GKV), the insurance company will reimburse a portion of the above costs according to the BEMA fee schedule. The patient is responsible for the remaining co-payment (Zuzahlung) and any surcharges for premium materials. For privately insured patients (PKV), the Quotation Estimate will be submitted directly to the insurer for pre-approval.
- Validity: This Quotation Estimate is valid for 30 calendar days from the date of issue. After this period, prices may be adjusted to reflect changes in material costs, laboratory fees, or applicable dental fee schedules in Berlin, Germany.
- Payment Terms: Payment is due within 14 days of the completion of the dental treatment. Our dental practice in Berlin, Germany, accepts bank transfer (SEPA), EC card, and cash. For treatments exceeding € 500, a 30% deposit is required at the time of scheduling.
- Insurance Coordination: The patient is responsible for confirming coverage with their dental insurance provider (whether statutory GKV or private PKV) prior to the commencement of treatment. Our practice in Berlin, Germany, will provide all necessary documentation, including the treatment plan and this Quotation Estimate, to facilitate the insurance claim process.
- Scope of Work: This Quotation Estimate covers only the procedures listed above. Any additional dental work identified during the course of treatment (e.g., unexpected complications during root canal therapy or extraction) will be communicated to the patient in writing and will require separate written consent before proceeding. Additional costs will be itemised in a supplementary Quotation Estimate.
- Warranty: All restorative dental work (composite fillings, crowns) carries a standard warranty of 24 months from the date of placement, provided the patient adheres to the recommended recall schedule (at least one dental check-up and prophylaxis per year at our Berlin, Germany practice).
- Data Protection: In accordance with the German Federal Data Protection Act (Bundesdatenschutzgesetz – BDSG) and the EU General Data Protection Regulation (GDPR), all patient data processed in connection with this Quotation Estimate and the subsequent dental treatment will be handled with strict confidentiality by our dental practice in Berlin, Germany.
- Dispute Resolution: In the event of any disagreement regarding the scope or cost of dental services, the patient may contact the Kassenärztliche Vereinigung Berlin (KVB) or the relevant dental chamber (Zahnärztekammer Berlin) for mediation. This Quotation Estimate is governed by the laws of the Federal Republic of Germany, with the city of Berlin as the place of jurisdiction.
By signing below, the patient acknowledges having received and reviewed this Quotation Estimate for dental treatment at our practice in Berlin, Germany. The patient confirms understanding of the proposed procedures, the associated costs, and the terms and conditions outlined above. The patient authorises the dental practice to proceed with the treatment as described in this Quotation Estimate.
Patient Signature & Date Dr. Anke Hoffmann, DDSPraxis Dr. med. dent. Anke Hoffmann
Berlin, Germany ⬇️ Download as DOCX Edit online as DOCX
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