Quotation Estimate Dentist in Peru Lima –Free Word Template Download with AI
Av. Javier Prado Este 1250, San Isidro, Lima, Peru
RUC: 20587432190 | Tel: +51 1 445-6789 | Email: [email protected]
Licensed by the Peruvian Ministry of Health (MINSA) – Registration No. 04521-LIM
Quotation EstimateQuotation Details
Quotation No.: QE-2025-00847
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Currency: Peruvian Sol (PEN / S/)
PENDING APPROVAL
Client Information
Name: María Elena Quispe Torres
DNI: 45678912
Address: Jr. Las Begonias 456, Miraflores, Lima, Peru
Phone: +51 987 654 321
Email: [email protected]
This Quotation Estimate is issued by Clínica Dental Sonrisa Andina, a registered and fully licensed Dentist practice operating in Peru Lima, specifically in the San Isidro district. The purpose of this document is to provide the client with a comprehensive, transparent, and itemized breakdown of all proposed dental services, associated materials, and professional fees. All pricing reflects current market rates in the Lima metropolitan area and complies with the regulations established by the Peruvian College of Dentists (Colegio Odontológico del Perú) and the Superintendencia Nacional de Salud (SUSALUD).
Itemized Services and Costs| # | Dental Service Description | Qty | Unit Price (S/) | Subtotal (S/) | Notes |
|---|---|---|---|---|---|
| 1 | Comprehensive Oral Examination & Digital X-Ray (Panoramic + Periapical) | 1 | 180.00 | 180.00 | Initial diagnostic session |
| 2 | Professional Dental Cleaning (Prophylaxis) with Ultrasonic Scaler | 1 | 250.00 | 250.00 | Includes polishing and fluoride application |
| 3 | Composite Resin Filling (Tooth #14 – Upper Right First Molar) | 1 | 420.00 | 420.00 | 3M Z350 composite material |
| 4 | Root Canal Treatment (Tooth #21 – Upper Left Central Incisor) | 1 | 1,850.00 | 1,850.00 | Single canal, includes obturation |
| 5 | Porcelain Crown (Tooth #21) – Zirconia Material | 1 | 2,400.00 | 2,400.00 | Lab work included, 2 visits |
| 6 | Extraction of Wisdom Tooth (Tooth #48 – Lower Right) | 1 | 650.00 | 650.00 | Simple extraction, local anesthesia |
| 7 | Orthodontic Consultation & Treatment Plan (Invisible Aligners) | 1 | 350.00 | 350.00 | Includes 3D scan and digital mockup |
| 8 | Follow-up Visit & Post-Operative Check (Week 2 and Week 6) | 2 | 80.00 | 160.00 | Monitoring healing and adjustments |
| TOTAL ESTIMATED COST (Before IGV 18%) | S/ 6,260.00 | ||||
| IGV (18% – Impuesto General a las Ventas) | S/ 1,126.80 | Mandatory tax in Peru | |||
| GRAND TOTAL (Quotation Estimate Amount) | S/ 7,386.80 | ||||
1. Validity: 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 due to changes in material costs, exchange rates, or regulatory updates within Peru Lima's healthcare sector.
2. Payment Terms: The client may choose to pay the full amount upon approval of this Quotation Estimate, or opt for a payment plan of three (3) equal monthly installments without additional interest. A 50% deposit is required to schedule the first appointment. Payments may be made via bank transfer (BCP, Interbank, or BBVA), Yape, Plin, or cash at our Lima office.
3. Scope of Work: The services listed in this Quotation Estimate are based on the initial clinical evaluation performed on June 10, 2025. Should the treating Dentist identify additional pathologies or complications during the course of treatment, a supplementary Quotation Estimate will be issued and must be approved in writing by the client before any additional procedures are performed.
4. Professional Standards: All dental procedures will be carried out by a licensed Dentist registered with the Colegio Odontológico del Perú, adhering to the ethical and technical standards mandated by the Peruvian Ministry of Health. Our clinic in Peru Lima maintains full compliance with SUSALUD regulations regarding sterilization, waste disposal, and patient safety protocols.
5. Warranty: All restorative work (crowns, fillings, root canals) is covered by a warranty period of twelve (12) months from the date of completion. This warranty covers material defects and procedural failures but does not extend to damage caused by trauma, neglect, or non-compliance with post-operative instructions.
6. Cancellation Policy: Appointments may be rescheduled up to 48 hours in advance without penalty. Cancellations made less than 48 hours before the scheduled visit will incur a fee of S/ 100.00 to cover reserved resources.
7. Confidentiality: In accordance with Peruvian data protection law (Ley N° 29733), all patient information contained in this Quotation Estimate and related clinical records will be treated with strict confidentiality and will not be disclosed to third parties without written consent.
Acceptance and AuthorizationBy signing below, the client acknowledges receipt of this Quotation Estimate, confirms understanding of all listed services, costs, and terms, and authorizes Clínica Dental Sonrisa Andina to proceed with the proposed dental treatment plan in Peru Lima. This document does not constitute a binding contract until the deposit is paid and the first appointment is confirmed.
Client SignatureMaría Elena Quispe Torres
DNI: 45678912
Date: _______________ Dentist / Authorized Representative
Dr. Ricardo Fernández Salas, D.D.S.
ROP: 12345 – Colegio Odontológico del Perú
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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