Quotation Estimate Dentist in Japan Tokyo –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Quotation No.: QTE-2025-0714-003

Date of Issue: 14 July 2025

Valid Until: 14 August 2025 (30 days)

Prepared By: Dr. Kenji Tanaka, DDS, PhD

Practice Location: Tokyo, Japan

Client Information

Name: Mr. Alexander J. Whitmore

Address: 45-3-12 Minami-Aoyama, Minato-ku, Tokyo 107-0062, Japan

Contact: +81-90-1234-5678

Email: [email protected]

Insurance Ref.: NHI-2025-88421

Dear Mr. Whitmore,

Thank you for visiting our Dentist practice in Japan Tokyo and for entrusting us with your dental care needs. Following your comprehensive consultation and diagnostic examination conducted on 10 July 2025 at our clinic in the Shibuya district of Tokyo, we are pleased to present this formal Quotation Estimate outlining the recommended treatment plan, associated costs, and all relevant terms. This Quotation Estimate has been prepared in accordance with the standards set by the Tokyo Dental Association and the Japan Dental Society, ensuring full transparency and compliance with all regulatory requirements applicable to dental services in Japan Tokyo.

Itemized Treatment Plan & Cost Breakdown

Item No.	Procedure / Service Description	Quantity	Unit Price (JPY)	Subtotal (JPY)
01	Comprehensive Oral Examination & Digital X-Ray (Panoramic + Periapical)	1	8,500	8,500
02	Professional Dental Cleaning & Scaling (Ultrasonic + Air Polishing)	1	12,000	12,000
03	Root Canal Treatment – Upper Right Molar (Tooth #16), 3 Canals	1	65,000	65,000
04	Ceramic Crown (Zirconia) – Upper Right Molar (Tooth #16)	1	58,000	58,000
05	Composite Resin Filling – Lower Left Premolar (Tooth #34)	1	15,000	15,000
06	Periodontal Assessment & Deep Cleaning (Subgingival Scaling, 4 Quadrants)	1	28,000	28,000
07	Fluoride Treatment & Occlusal Sealants (4 Molars)	1	6,000	6,000
08	Follow-up Consultation & Post-Treatment Review (2 Sessions)	2	5,000	10,000
09	Temporary Crown Fabrication & Fitting	1	8,000	8,000
10	Prescription Medication (Antibiotics & Analgesics, 7-day course)	1	3,500	3,500
Total Estimated Cost (Before Tax):				224,000
Consumption Tax (10%):				22,400
Grand Total (Tax Inclusive):				246,400
Estimated National Health Insurance (NHI) Reimbursement (30%):				-73,920
Patient Out-of-Pocket Amount (70%):				172,480

Note: This Quotation Estimate is based on the clinical findings as of the examination date. Should additional procedures become necessary during the course of treatment (e.g., discovery of further decay, need for endodontic retreatment, or periodontal intervention beyond the scope outlined above), a revised Quotation Estimate will be issued and presented to you for written approval prior to any additional work being performed. All prices listed are in Japanese Yen (JPY) and reflect the standard fee schedule of our Dentist practice in Japan Tokyo as of July 2025. Terms & Conditions of This Quotation Estimate

Validity Period: This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, prices may be subject to revision in accordance with the Tokyo Dental Association's updated fee guidelines and any changes in material costs within Japan Tokyo.
Payment Schedule: The total patient out-of-pocket amount of ¥172,480 shall be payable in three installments: 40% upon acceptance of this Quotation Estimate, 35% upon completion of the root canal treatment and temporary crown placement, and the remaining 25% upon final crown cementation and completion of all procedures. Payment may be made by cash, credit card (Visa, Mastercard, JCB, Amex), or bank transfer to our designated account at MUFG Bank, Shibuya Branch.
Insurance Coverage: The estimated National Health Insurance (NHI) reimbursement of 30% is calculated based on the standard 3-coin (3割) self-pay ratio for patients aged 18–69. The actual reimbursement amount is subject to verification by the Tokyo Metropolitan Bureau of National Health Insurance. Our clinic will submit all necessary documentation on your behalf.
Treatment Timeline: The complete treatment plan is expected to be completed within six (6) to eight (8) weeks from the date of your first treatment appointment, assuming no complications arise. Specific appointment dates will be coordinated with our scheduling team in Tokyo.
Warranty: All ceramic crowns and composite restorations are covered under a two-year warranty against material defects and debonding under normal use. This warranty does not cover damage resulting from trauma, bruxism (teeth grinding), or failure to attend scheduled follow-up appointments.
Cancellation Policy: Appointments cancelled with less than 48 hours' notice may incur a fee of ¥5,000 per session. This policy is in line with standard practices among Dentist offices in Japan Tokyo.
Confidentiality: All patient records, radiographic images, and treatment details are handled in strict accordance with Japan's Personal Information Protection Act (PIPA) and the Medical Confidentiality provisions of the Medical Practitioners Act. Your data will not be shared with any third party without your explicit written consent.
Acceptance: By signing below, you acknowledge that you have read, understood, and agree to all terms outlined in this Quotation Estimate. Your signature constitutes formal acceptance of the proposed treatment plan and associated costs as presented by our Dentist practice in Japan Tokyo.

Acceptance & Authorization

For Tokyo Central Dental Clinic

Dr. Kenji Tanaka, DDS, PhD

Chief Dentist & Practice Director

Signature & Date

Client Acknowledgment

Mr. Alexander J. Whitmore

Patient

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