Quotation Estimate Dentist in Germany Frankfurt –Free Word Template Download with AI
Comprehensive Dental Treatment Plan & Cost Estimate
Frankfurt Dental Excellence CenterHauptstraße 142
60311 Frankfurt am Main
Germany
Tel: +49 (0)69 1234 5678
Email: [email protected] Quotation Estimate No.: QE-2025-04872
Date of Issue: 15 June 2025
Valid Until: 15 August 2025
Prepared By: Dr. med. dent. Anna Schneider Patient Information
Patient Details
Name: Michael Weber
Date of Birth: 22 March 1985
Address: Goethestraße 8, 60313 Frankfurt am Main, Germany
Phone: +49 (0)69 8765 4321
Email: [email protected]
Insurance & Billing
Insurance Provider: TK – Technische Krankenkasse
Insurance No.: TK-2025-884312
Cost Class: 30 (Standard)
Referring Dentist: Dr. Thomas Müller, Frankfurt
Billing Method: Direct billing to insurance + patient co-payment
Treatment Plan & Quotation Estimate BreakdownThe following Quotation Estimate has been carefully prepared by our senior Dentist, Dr. med. dent. Anna Schneider, following a comprehensive clinical examination, digital X-ray imaging, and periodontal assessment conducted at our practice in Germany Frankfurt on 10 June 2025. All prices listed below are in Euros (EUR) and include applicable German value-added tax (Mehrwertsteuer) at the current rate of 19%.
| No. | Treatment / Procedure | GOZ Code | Factor | Unit Price (EUR) | Quantity | Total (EUR) |
|---|---|---|---|---|---|---|
| 1 | Comprehensive diagnostic examination including intraoral photography, digital panoramic X-ray, and periodontal charting | GOZ 1010, 1020, 1030 | 1.0 | 187.50 | 1 | 187.50 |
| 2 | Professional dental prophylaxis (scaling and polishing) – upper and lower arch | GOZ 1020 | 1.0 | 128.00 | 1 | 128.00 |
| 3 | Removal of amalgam filling, tooth #16 (upper left first molar), with composite restoration | GOZ 2080, 2110 | 1.0 | 245.00 | 1 | 245.00 |
| 4 | Root canal treatment (endodontic therapy), tooth #21 (upper right central incisor), single canal | GOZ 2510, 2520 | 1.0 | 485.00 | 1 | 485.00 |
| 5 | Ceramic inlay (zirconia) for tooth #21 following endodontic treatment | GOZ 2120 | 1.0 | 620.00 | 1 | 620.00 |
| 6 | Extraction of tooth #48 (lower right third molar / wisdom tooth), surgical removal with suturing | GOZ 3010, 3020 | 1.0 | 310.00 | 1 | 310.00 |
| 7 | Placement of titanium dental implant (3.75 mm x 13 mm), lower jaw, site #47 | GOZ 3110, 3120 | 1.0 | 1,250.00 | 1 | 1,250.00 |
| 8 | Abutment and custom ceramic crown for implant site #47 | GOZ 3130, 3140 | 1.0 | 890.00 | 1 | 890.00 |
| 9 | Follow-up appointments (3 sessions) for healing monitoring, suture removal, and final adjustment | GOZ 1010 | 1.0 | 45.00 | 3 | 135.00 |
| 10 | Emergency consultation and interim management (if required during healing period) | GOZ 1010 | 1.0 | 65.00 | 1 | 65.00 |
| Subtotal (before insurance reimbursement): | 4,215.50 | |||||
| Estimated insurance reimbursement (TK, Cost Class 30): | -1,847.20 | |||||
| Patient Co-Payment (Eigenanteil): | 2,368.30 | |||||
- This Quotation Estimate is issued by Frankfurt Dental Excellence Center, a registered dental practice in Germany Frankfurt, and is valid for a period of 60 days from the date of issue. After this period, prices may be adjusted to reflect current material costs, GOZ fee schedule updates, or changes in insurance reimbursement rates.
- All treatments listed in this Quotation Estimate will be performed by our qualified Dentist, Dr. med. dent. Anna Schneider, or by a supervised associate dentist under her direct clinical supervision, in full compliance with the German Dental Association (Kassenzahnärztliche Vereinigung Hessen – KZV Hessen) regulations.
- The estimated insurance reimbursement amount is based on the current fee schedule of TK – Technische Krankenkasse for Cost Class 30. The actual reimbursement may vary depending on the final treatment outcome, additional findings during the procedure, or changes in the patient's insurance status. The patient is responsible for any difference between the estimated and actual reimbursement.
- Implant placement (items 7 and 8) is not covered by statutory health insurance in Germany. The full cost of 2,140.00 EUR for the implant and crown is the patient's responsibility. This Quotation Estimate reflects the standard GOZ pricing; premium implant systems or additional bone grafting procedures would incur additional charges not included herein.
- Should the Dentist identify additional pathologies or complications during the course of treatment that were not apparent at the time of the initial examination, a supplementary Quotation Estimate will be provided to the patient for written approval before any additional procedures are performed.
- Payment of the patient co-payment is due within 14 days of the final treatment session. Our practice in Germany Frankfurt accepts bank transfer (SEPA), credit card (Visa, Mastercard, American Express), and direct debit. A 1.5% surcharge applies to credit card payments.
- This Quotation Estimate does not constitute a binding contract for treatment. The patient retains the right to decline any or all items listed. The Dentist reserves the right to modify the treatment plan based on clinical findings at the time of each appointment.
- All patient data processed in connection with this Quotation Estimate is handled in strict accordance with the European General Data Protection Regulation (GDPR / DSGVO) and the German Federal Data Protection Act (BDSG). Data is stored securely at our practice in Frankfurt am Main and will not be shared with third parties without explicit patient consent.
- In the event of a dispute regarding the Quotation Estimate or treatment costs, the patient may contact the KZV Hessen (Kassenzahnärztliche Vereinigung Hessen) at their office in Frankfurt for an independent cost review.
By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the proposed treatment plan and associated costs, and authorizes the Dentist at Frankfurt Dental Excellence Center to proceed with the treatments as described. The patient confirms that all relevant medical history, allergies, and current medications have been disclosed to the treating Dentist.
Patient Signature & DateMichael Weber Dentist / Practice Representative & Date
Dr. med. dent. Anna Schneider ⬇️ Download as DOCX Edit online as DOCX
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