Quotation Estimate Dentist in Russia Saint Petersburg –Free Word Template Download with AI
Professional Dental Care in the Heart of Saint Petersburg, Russia
12 Fontanka Embankment, Saint Petersburg, 191025, Russian Federation
Phone: +7 (812) 335-78-42 | Email: [email protected]
License No. ЛО-78-01-003456 | OGRN: 1087847012345
Quotation EstimateQuotation Details
Quotation No.: QTE-SPB-2025-04871
Date of Issue: 14 June 2025
Valid Until: 14 July 2025 (30 days)
Currency: Russian Rubles (RUB / ₽)
Prepared By: Dr. Alexander V. Petrov, Chief Dentist
Client Information
Client Name: [Full Name of Patient]
Address: [Street, Apt.], Saint Petersburg, Russia
Phone: +7 (___) ___-__-__
Passport / ID No.: [__________]
Insurance Policy (if applicable): [__________]
Dear Valued Patient,
Thank you for choosing Neva Dental Clinic for your dental care needs in Saint Petersburg, Russia. This Quotation Estimate has been prepared following your comprehensive dental examination conducted on 12 June 2025. Our team of experienced dentists has carefully assessed your oral health and developed a detailed treatment plan tailored to your specific requirements. The following Quotation Estimate outlines all recommended dental procedures, associated costs, and the projected timeline for completion of your treatment.
Itemized Dental Services and Costs| No. | Dental Procedure / Service | Description | Qty | Unit Price (RUB) | Total (RUB) |
|---|---|---|---|---|---|
| 1 | Full Oral Examination & Digital X-Ray | Comprehensive diagnostic assessment including panoramic radiograph and intraoral photographs | 1 | 3,500 | 3,500 |
| 2 | Professional Dental Cleaning (Ultrasonic Scaling) | Removal of plaque, tartar, and calculus using ultrasonic scaler with polishing | 1 | 5,200 | 5,200 |
| 3 | Composite Resin Filling (Tooth #14, #25) | Restoration of two molars with light-cured composite material (3M Z350 XT) | 2 | 7,800 | 15,600 |
| 4 | Root Canal Treatment (Tooth #21) | Endodontic therapy including canal instrumentation, irrigation, and obturation | 1 | 18,500 | 18,500 |
| 5 | Ceramic Crown (Tooth #21) | Full zirconia crown fabrication and cementation following root canal completion | 1 | 32,000 | 32,000 |
| 6 | Extraction of Wisdom Tooth (Tooth #38) | Surgical removal of impacted mandibular third molar under local anesthesia | 1 | 12,000 | 12,000 |
| 7 | Periodontal Therapy (Localized) | Deep scaling and root planing in the upper right quadrant | 1 | 9,500 | 9,500 |
| 8 | Follow-up Consultations (3 visits) | Post-treatment check-ups, suture removal, and healing assessment | 3 | 1,200 | 3,600 |
| 9 | Prescription Medications & Aftercare Kit | Antibiotics, analgesics, antiseptic mouthwash, and healing ointment | 1 | 2,800 | 2,800 |
| Subtotal | 102,700 | ||||
| VAT (20%) | 20,540 | ||||
| TOTAL AMOUNT DUE | 123,240 ₽ | ||||
The complete dental treatment plan outlined in this Quotation Estimate is projected to be completed over a period of approximately six to eight weeks, subject to the healing progress of the patient. The initial procedures (examination, cleaning, fillings, and extraction) will be scheduled within the first two weeks. The root canal treatment and subsequent ceramic crown placement for Tooth #21 will require two to three separate visits spaced one week apart. Periodontal therapy will be performed in a dedicated session following the completion of the extraction healing phase. All follow-up consultations will be scheduled at the dentist's discretion based on clinical observations.
Payment Terms1. A deposit of 30% (36,972 ₽) of the total Quotation Estimate amount is required at the time of acceptance to reserve your appointment slots at our Saint Petersburg clinic.
2. The remaining balance (86,268 ₽) shall be payable in two equal installments: 50% upon completion of the root canal treatment and 50% upon final crown cementation.
3. Accepted payment methods include: cash (RUB), bank transfer to the clinic account (Sberbank, BIC: 044030643), Visa/MasterCard, and Mir card. International wire transfers are accepted with a 3% processing surcharge.
4. Late payments exceeding 10 business days will incur a penalty of 0.1% per day on the outstanding balance, in accordance with the Civil Code of the Russian Federation.
Terms and Conditions1. This Quotation Estimate is valid for 30 calendar days from the date of issue. Prices are subject to change after the validity period expires due to fluctuations in material costs and exchange rates applicable in Russia.
2. All dental procedures will be performed by licensed dentists registered with the Ministry of Health of the Russian Federation. The clinic operates in full compliance with SanPiN 2.1.3.2630-10 and all applicable federal and municipal regulations for medical institutions in Saint Petersburg.
3. The patient consents to the treatment plan as described in this Quotation Estimate. Any additional procedures identified during treatment that were not anticipated at the time of the initial examination will be communicated to the patient in writing before commencement, with a supplementary Quotation Estimate provided.
4. A warranty of 24 months is provided on all restorative work (fillings, crowns, and root canal treatments) against material defects and technical failures under normal use. The warranty does not cover damage resulting from trauma, neglect, or failure to attend scheduled follow-up appointments.
5. The patient's personal and medical data will be processed in strict accordance with Federal Law No. 152-FZ "On Personal Data" of the Russian Federation. Medical records will be retained at the clinic for a minimum of 15 years as required by Russian healthcare legislation.
6. In the event of force majeure or circumstances beyond the clinic's control (including but not limited to government-mandated closures in Saint Petersburg), appointment rescheduling will be arranged at no additional cost to the patient.
Acceptance and SignaturesBy signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the proposed dental treatment plan, and agrees to the payment terms and conditions outlined herein. This document constitutes a binding agreement between Neva Dental Clinic and the patient for the services described.
For Neva Dental Clinic:
Dr. Alexander V. Petrov
Chief Dentist / Medical Director
Signature & DatePatient / Authorized Representative:
[Full Name]
[Passport / ID Number]
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