Quotation Estimate Dentist in South Korea Seoul –Free Word Template Download with AI
Seoul Premier Dental Clinic — South Korea Seoul
Dentist Services • Comprehensive Dental Care • Seoul, South Korea
CLIENT INFORMATION| Field | Details |
|---|---|
| Patient Name: | Mr. James A. Whitfield |
| Residence: | 45, Itaewon-ro, Yongsan-gu, Seoul, South Korea |
| Contact Number: | +82-10-5567-8901 |
| Email: | [email protected] |
| Insurance Provider: | National Health Insurance Service (NHIS), South Korea — Member ID: 1-00-482917-3 |
| Referring Dentist: | Dr. Hana Kim, Yongsan Dental Center, Seoul |
| # | Service Description | Procedure Code | Qty | Unit Price (KRW) | Subtotal (KRW) |
|---|---|---|---|---|---|
| 1 | Comprehensive Initial Consultation & Digital Panoramic X-Ray (CBCT Scan) — Performed by Lead Dentist in Seoul | SPDC-INIT-001 | 1 | ₩ 180,000 | ₩ 180,000 |
| 2 | Full Mouth Scaling & Root Planing (Ultrasonic + Manual) — 4 Quadrants | SPDC-SCALE-004 | 4 | ₩ 95,000 | ₩ 380,000 |
| 3 | Composite Resin Filling — Tooth #14 (Upper Right First Molar), 2 Surfaces | SPDC-FILL-014 | 1 | ₩ 150,000 | ₩ 150,000 |
| 4 | Root Canal Treatment (Endodontic Therapy) — Tooth #21 (Upper Left Central Incisor), Single Canal | SPDC-RC-021 | 1 | ₩ 420,000 | ₩ 420,000 |
| 5 | Porcelain Crown (Zirconia) — Tooth #21, Post-Endodontic Restoration | SPDC-CROWN-021 | 1 | ₩ 580,000 | ₩ 580,000 |
| 6 | Wisdom Tooth Extraction — Tooth #38 (Lower Left Third Molar), Impacted, Surgical Removal | SPDC-EXTR-038 | 1 | ₩ 350,000 | ₩ 350,000 |
| 7 | Professional Teeth Whitening (In-Office LED System) — Full Arch | SPDC-WHITEN-001 | 1 | ₩ 280,000 | ₩ 280,000 |
| 8 | Follow-Up Visit & Post-Operative Check (Week 2 & Week 6) — Includes Digital X-Ray Verification | SPDC-FOLLOW-002 | 2 | ₩ 50,000 | ₩ 100,000 |
| 9 | Custom-Fitted Night Guard (Occlusal Splint) — Acrylic, Full Arch | SPDC-NG-001 | 1 | ₩ 220,000 | ₩ 220,000 |
| 10 | Annual Dental Health Maintenance Plan (12 Months) — Includes 2 Cleanings, 2 Check-Ups, 4 X-Rays | SPDC-ANNUAL-001 | 1 | ₩ 450,000 | ₩ 450,000 |
| SUBTOTAL (All Services) | ₩ 3,110,000 | ||||
| NHIS Insurance Coverage (Approx. 60% of Covered Items) | −₩ 1,244,000 | ||||
| VAT (10%) on Patient-Portion | ₩ 186,600 | ||||
| TOTAL ESTIMATED PATIENT RESPONSIBILITY | ₩ 2,052,600 | ||||
General Terms
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. Prices are subject to revision after the expiration date due to potential changes in material costs, NHIS reimbursement rates, or Seoul municipal health regulations.
- Payment Schedule: A deposit of 30% of the total estimated patient responsibility (₩ 615,780) is required at the time of scheduling the first procedure. The remaining balance is due upon completion of all scheduled treatments. Payment may be made via bank transfer (Kookmin Bank, Seoul Gangnam Branch, Acct: 912-34-5678-901), credit card (Visa, Mastercard, JCB, UnionPay), or NHIS direct billing for covered items.
- Scheduling: All procedures will be coordinated by the Lead Dentist and the clinic's scheduling team in Seoul. The estimated total treatment timeline is six (6) weeks, subject to healing periods between surgical and restorative phases. The patient will be notified of any schedule adjustments via SMS or email.
- Insurance Verification: The patient is responsible for confirming active NHIS enrollment prior to the first visit. The clinic will submit all NHIS-eligible claims on behalf of the patient. Any discrepancy between the estimated insurance coverage in this Quotation Estimate and the actual NHIS reimbursement will be communicated in writing within five (5) business days of the NHIS determination.
- Warranty: All restorative work (crowns, fillings, night guard) carries a warranty of twenty-four (24) months from the date of placement, provided the patient attends all scheduled follow-up appointments. The warranty does not cover damage resulting from trauma, bruxism without use of the prescribed night guard, or failure to attend maintenance visits.
- Cancellation Policy: Appointments cancelled with less than 48 hours' notice will incur a fee of ₩ 50,000 per cancelled session. No fee applies to cancellations made more than 48 hours in advance.
- Confidentiality: All patient records, radiographic images, and treatment plans are stored in accordance with the Personal Information Protection Act (PIPA) of South Korea. No data will be shared with third parties without written consent, except as required by Korean law or NHIS audit procedures.
- Language & Communication: The Lead Dentist and clinic staff in Seoul provide services in both Korean and English. All written documentation, including this Quotation Estimate, is available in both languages upon request.
- Dispute Resolution: Any disputes arising from this Quotation Estimate or the services rendered shall be resolved through the Seoul Metropolitan Medical Dispute Mediation Committee in accordance with Korean medical service regulations.
By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the estimated costs, treatment plan, and terms outlined above, and authorizes the Lead Dentist at Seoul Premier Dental Clinic to proceed with the described dental services in Seoul, South Korea.
Patient SignatureName: James A. Whitfield
Date: ______________________ Dentist / Clinic Representative
Name: Dr. Min-Ji Park, DDS
Seoul Premier Dental Clinic
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT