Quotation Estimate Dentist in South Africa Johannesburg –Free Word Template Download with AI
Savanna Dental Clinic • 142 Rivonia Road, Sandton, Johannesburg, 2196, South Africa
| Quotation Estimate No.: | QTE-2025-04871 |
| Date of Issue: | 14 June 2025 |
| Valid Until: | 14 July 2025 (30 calendar days) |
| Prepared By: | Dr. Thandiwe Mokoena, Principal Dentist & Practice Owner |
| Client Name: | Mr. James P. van der Merwe |
| Client Address: | 88 Waterfall Drive, Randburg, Johannesburg, 2194, South Africa |
| Medical Aid Scheme: | Discovery Health — Plan: Vitality Plus (Member No. DH-7742-9910) |
| Contact Number: | +27 11 456 7890 |
| Email: | [email protected] |
1. Purpose of This Quotation Estimate
This Quotation Estimate has been prepared by our registered Dentist practice in South Africa Johannesburg to provide Mr. James P. van der Merwe with a comprehensive, itemised financial breakdown of the proposed dental treatment plan. Following a full clinical examination, intraoral radiography (OPG and periapical X-rays), and a periodontal assessment conducted on 10 June 2025, our Dentist team has identified several areas requiring intervention. This document serves as a formal Quotation Estimate outlining the scope of work, associated costs in South African Rand (ZAR), and the expected timeline for completion of all recommended procedures.
2. Scope of Dental Services & Itemised Costs
| Ref | Procedure / Service Description | Quantity | Unit Price (ZAR) | Subtotal (ZAR) |
|---|---|---|---|---|
| 01 | Comprehensive Dental Examination & Treatment Planning (Dentist consultation, OPG, 6 periapical X-rays, periodontal charting) | 1 | R 1,250.00 | R 1,250.00 |
| 02 | Ultrasonic Scaling & Polishing (full mouth, above and below gumline) | 1 | R 1,850.00 | R 1,850.00 |
| 03 | Root Canal Treatment — Tooth #16 (upper left first molar), including gutta-percha obturation and temporary restoration | 1 | R 6,500.00 | R 6,500.00 |
| 04 | Custom Porcelain Crown — Tooth #16 (CAD/CAM milled, zirconia-reinforced, including temporary crown and final cementation) | 1 | R 8,200.00 | R 8,200.00 |
| 05 | Composite Resin Restoration — Tooth #34 (lower left first premolar), Class II cavity, two-surface filling | 1 | R 2,400.00 | R 2,400.00 |
| 06 | Extraction — Tooth #48 (lower right third molar, impacted), including local anaesthesia, surgical removal, and post-operative instructions | 1 | R 3,800.00 | R 3,800.00 |
| 07 | Prophylaxis & Fluoride Varnish Application (post-extraction follow-up, 4 weeks) | 1 | R 950.00 | R 950.00 |
| 08 | Follow-up Consultation & Radiographic Review (Dentist re-examination at 6 weeks) | 1 | R 650.00 | R 650.00 |
| TOTAL ESTIMATED COST (excl. VAT) | R 25,600.00 | |||
| VAT @ 15% | R 3,840.00 | |||
| GRAND TOTAL (incl. VAT) | R 29,440.00 | |||
3. Medical Aid & Payment Information
Our Dentist practice in South Africa Johannesburg is a registered provider with Discovery Health, Bonitas, Medihelp, and Momentum Medical Schemes. Based on the Vitality Plus plan benefits, an estimated R 18,750.00 of the above Quotation Estimate is expected to be covered by your medical aid. The remaining balance of approximately R 10,690.00 (inclusive of VAT) will be the client's responsibility. A pre-authorisation form will be submitted to Discovery Health prior to commencing the root canal and crown procedures. Payment of the client's portion is due in full at the time of the final appointment. We accept EFT, debit/credit card, and cash. A 50% deposit is required to secure the appointment schedule for the crown fabrication.
4. Treatment Timeline
The complete treatment plan outlined in this Quotation Estimate is expected to span approximately six (6) weeks from the initial procedure date. The root canal treatment and temporary crown will be completed in a single two-hour session. The final porcelain crown will be fabricated by our in-house dental laboratory over a period of ten (10) working days. The extraction of tooth #48 is scheduled for the same day as the root canal procedure to minimise the number of visits. The follow-up consultation will be booked for six weeks post-extraction to confirm healing.
Important Notes:- This Quotation Estimate is valid for thirty (30) days from the date of issue. Prices are subject to change after the validity period.
- All costs are quoted in South African Rand (ZAR) and are inclusive of standard materials. Any unforeseen complications (e.g., additional canals, bone grafting) will be communicated to the client prior to additional charges.
- The Dentist performing all procedures is Dr. Thandiwe Mokoena, registered with the Health Professions Council of South Africa (HPCSA No. 0012345678).
- Warranty: All restorations carry a 12-month workmanship warranty from the date of final cementation.
- This Quotation Estimate does not constitute a binding contract until signed and accepted by both parties.
5. Terms & Conditions
- 1. This Quotation Estimate is issued by Savanna Dental Clinic, a registered dental practice operating in Johannesburg, South Africa, in compliance with the National Health Act 61 of 2003.
- 2. The client acknowledges that the costs listed herein are estimates based on the clinical findings at the time of examination. The final invoice may vary by up to 10% should additional clinical requirements arise.
- 3. Cancellation of scheduled appointments must be communicated at least 48 hours in advance. Late cancellations or no-shows will incur a fee of R 500.00 per missed appointment.
- 4. The practice reserves the right to refer specific procedures (e.g., orthodontics, oral surgery beyond simple extractions) to a specialist colleague within the Johannesburg dental network, with prior written consent from the client.
- 5. All patient records, radiographs, and treatment plans remain the property of the Dentist practice and will be retained in accordance with South African POPIA (Protection of Personal Information Act) regulations for a minimum of seven (7) years.
- 6. Disputes arising from this Quotation Estimate shall be resolved in the Magistrate's Court of Johannesburg, South Africa.
______________________________
Dr. Thandiwe Mokoena
Date: _______________ Accepted & Signed by (Client):
______________________________
Mr. James P. van der Merwe
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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