Quotation Estimate Dentist in Spain Madrid –Free Word Template Download with AI
Clínica Dental Madrid Central • C/ Gran Vía 42, 3º 18013 Madrid, Spain
Tel: +34 915 555 012 • Email: [email protected] • NIF: B-87654321
1. Client Information
| Full Name: | Mr. James Robert Thompson |
| Address: | C/ Alcalá 115, 2º B, 28009 Madrid, Spain |
| NIE / DNI: | X-1234567-Z |
| Contact: | +34 612 345 678 • [email protected] |
| Insurance Provider: | Adeslas Seguros (Policy No. ADL-998877) |
2. Scope of Dental Services — Quotation Estimate Details
This Quotation Estimate has been prepared by our licensed Dentist team at Clínica Dental Madrid Central following a comprehensive clinical examination and diagnostic imaging (panoramic radiograph and intraoral photographs) conducted on 10 June 2025. The following dental treatments are proposed for the patient in Madrid, Spain, in accordance with the clinical findings and the patient's stated preferences regarding aesthetic and functional outcomes.
| Ref. | Dental Procedure | Description | Qty | Unit Price (EUR) | Subtotal (EUR) |
|---|---|---|---|---|---|
| 01 | Full Oral Hygiene & Scaling | Ultrasonic scaling, air-polishing, and professional fluoride application for both arches | 1 | 120.00 | 120.00 |
| 02 | Composite Resin Restoration (Tooth #24) | Direct composite filling, medium cavity, including shade matching and polishing | 1 | 185.00 | 185.00 |
| 03 | Porcelain Crown (Tooth #16) | Full ceramic (zirconia) crown, including temporary crown, impression, and final cementation | 1 | 650.00 | 650.00 |
| 04 | Root Canal Treatment (Tooth #36) | Endodontic therapy, single canal, including obturation and temporary restoration | 1 | 420.00 | 420.00 |
| 05 | Teeth Whitening (In-Office) | LED-assisted professional whitening session, 60 minutes, including pre- and post-care kit | 1 | 295.00 | 295.00 |
| 06 | Diagnostic Imaging & Consultation | Panoramic X-ray, periapical radiographs (2), clinical examination, and treatment planning | 1 | 85.00 | 85.00 |
| 07 | Follow-Up Visit (2 weeks post-treatment) | Post-operative check, suture removal if applicable, and adjustment of restorations | 1 | 50.00 | 50.00 |
| Subtotal (before VAT): | 1,805.00 | ||||
| VAT (IVA) 21% — Spain: | 379.05 | ||||
| TOTAL ESTIMATED COST: | 2,184.05 | ||||
3. Insurance & Payment Information
Insurance Coverage: Based on the pre-authorization received from Adeslas Seguros (reference ADL-998877), the insurer will cover an estimated 70% of the subtotal for items 01 through 04, amounting to approximately €1,102.50. The patient is responsible for the remaining 30% co-payment plus the full cost of items 05, 06, and 07, as these are classified as elective or diagnostic services under the Adeslas plan in Spain.
Payment Schedule: A 40% deposit (€873.62) is required at the time of accepting this Quotation Estimate to reserve the treatment dates. The remaining balance is due upon completion of the final procedure. We accept bank transfer (IBAN: ES91 2100 0418 4502 0005 1332), credit/debit cards (Visa, Mastercard), and cash. Instalment plans of up to 6 months interest-free are available upon request.
4. Terms & Conditions of This Quotation Estimate
- Validity: This Quotation Estimate is valid for 30 calendar days from the date of issue. Prices are subject to change after the expiry date due to material cost fluctuations or regulatory updates in Spain.
- Estimate Nature: This document constitutes a Quotation Estimate and not a binding contract. Final costs may vary by up to ±10% depending on intra-operative findings (e.g., additional caries discovered during the root canal treatment on tooth #36, or the need for a post-and-core before crown placement).
- Regulatory Compliance: All dental procedures will be performed in strict compliance with the Spanish Dental Council regulations (Consejo General de Colegios Oficiales de Odontólogos y Estomatólogos de España), the Madrid regional health authority (Servicio Madrileño de Salud), and EU medical device directives applicable to dental materials.
- Warranty: A 24-month warranty is provided on all restorations (composite fillings, porcelain crown) against material defects under normal use. This warranty does not cover damage caused by trauma, bruxism, or failure to attend scheduled follow-up appointments.
- Confidentiality: All patient data processed in connection with this Quotation Estimate and subsequent treatment will be handled in accordance with the Spanish Organic Law 3/2018 (LOPDGDD) and the EU General Data Protection Regulation (GDPR). Data will be stored at our Madrid clinic premises and will not be shared with third parties except as required by law or the patient's insurance provider.
- Cancellation Policy: Appointments may be rescheduled up to 48 hours in advance without charge. Cancellations within 48 hours or no-shows will incur a fee of 50% of the scheduled procedure cost.
- Dispute Resolution: Any disputes arising from this Quotation Estimate or the subsequent dental treatment shall be resolved in the courts of Madrid, Spain, in accordance with Spanish civil and consumer protection law (Ley General para la Defensa de los Consumidores y Usuarios).
5. Acceptance & Authorization
By signing below, the patient acknowledges having received and reviewed this Quotation Estimate for dental services in Madrid, Spain. The patient confirms understanding of the proposed treatment plan, the estimated costs, the insurance coverage details, and the terms and conditions outlined above. The patient authorizes the Dentist team at Clínica Dental Madrid Central to proceed with the listed procedures upon receipt of the required deposit.
Patient SignatureMr. James Robert Thompson
Date: _______________
Dentist / Clinic RepresentativeDr. Elena García Martín
Clínica Dental Madrid Central
Date: _______________
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