Quotation Estimate Dentist in Sri Lanka Colombo –Free Word Template Download with AI
BrightSmile Dental Clinic | 42, Galle Road, Colombo 03, Sri Lanka
Tel: +94 11 234 5678 | Email: [email protected] | Reg. No: SL-DENT-2019-0042
This Quotation Estimate is issued by BrightSmile Dental Clinic, a registered and licensed Dentist practice operating in the heart of Sri Lanka Colombo, to provide a comprehensive and transparent breakdown of all proposed dental treatments, diagnostic procedures, and associated professional fees. Our clinic has served the dental health needs of residents and visitors in Colombo and the greater Western Province of Sri Lanka for over twelve years, maintaining the highest standards of clinical excellence, patient safety, and ethical practice as mandated by the Sri Lanka Dental Association.
The following Quotation Estimate covers a full-course dental treatment plan as recommended by our senior Dentist, Dr. Anjali Fernando (MDSc, FDS RCS), following a comprehensive clinical examination, intraoral radiography, and digital panoramic imaging conducted on 10 June 2025. All pricing is quoted in Sri Lankan Rupees (LKR) and includes applicable Goods and Services Tax (GST) at the prevailing rate of 18% as enforced by the Department of Inland Revenue, Sri Lanka.
2. Itemized Treatment Plan & Cost Breakdown| # | Procedure / Service | Description | Qty | Unit Price (LKR) | Subtotal (LKR) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dental Examination & Consultation | Full oral assessment, medical history review, and treatment planning by a senior Dentist in Colombo | 1 | 5,500 | 5,500 |
| 2 | Digital Panoramic X-Ray (OPG) | Full-jaw radiographic imaging for diagnostic purposes | 1 | 4,200 | 4,200 |
| 3 | Ultrasonic Scaling & Polishing (Full Mouth) | Removal of calculus, plaque, and surface stains; professional prophylaxis | 1 | 12,000 | 12,000 |
| 4 | Composite Resin Fillings (Posterior Teeth) | Class II and Class V restorations using 3M Z350 XT composite material | 4 | 18,500 | 74,000 |
| 5 | Root Canal Treatment (Single Root, Premolar) | Endodontic therapy including access, instrumentation, obturation, and temporary restoration | 2 | 45,000 | 90,000 |
| 6 | Full-Ceramic Crown (E.max / Lithium Disilicate) | Custom-fabricated crown for post-endodontic tooth protection; includes temporary crown | 2 | 65,000 | 130,000 |
| 7 | Extraction of Impacted Third Molar (Wisdom Tooth) | Surgical removal under local anaesthesia; includes post-operative care and one follow-up visit | 1 | 35,000 | 35,000 |
| 8 | Professional Teeth Whitening (In-Clinic, ZOOM) | Single-session LED-activated whitening treatment for visible smile enhancement | 1 | 48,000 | 48,000 |
| 9 | Follow-Up Visits & Adjustments | Up to three post-treatment review appointments within 90 days | 3 | 2,500 | 7,500 |
| 10 | Prescription Medication & Post-Operative Kit | Analgesics, antibiotics (if indicated), antiseptic mouthwash, and soft diet guidance | 1 | 6,800 | 6,800 |
| Subtotal (Before GST): | LKR 413,000 | ||||
| GST @ 18%: | LKR 74,340 | ||||
| GRAND TOTAL (Inclusive of GST): | LKR 487,340 | ||||
- Advance Payment: A non-refundable deposit of 30% (LKR 146,202) is required to confirm the treatment schedule and reserve the Dentist's clinical time in Colombo.
- Balance Payment: The remaining 70% (LKR 341,138) is due upon completion of all procedures, no later than the final follow-up visit.
- Accepted Payment Methods: Cash, bank transfer (Commercial Bank, HNB, or CMB), credit/debit cards (Visa, Mastercard), and eZ Cash. No additional surcharge applies for card payments.
- Installment Option: Patients may request a three-month interest-free installment plan subject to credit verification. A processing fee of LKR 5,000 applies.
- This Quotation Estimate is valid for thirty (30) days from the date of issue. Prices are subject to revision in accordance with any changes in the Sri Lankan government's GST policy or significant fluctuations in the import cost of dental materials.
- All treatments will be performed by a qualified and registered Dentist or dental specialist at our Colombo clinic in strict compliance with the Dental Practitioners Act (No. 14 of 1972) of Sri Lanka.
- The patient consents to the taking and storage of clinical photographs and radiographic images for treatment documentation and quality assurance purposes.
- A written warranty of twelve (12) months is provided on all restorative work (crowns, fillings, and endodontic treatments) against material or workmanship defects under normal use. This warranty does not cover damage due to trauma, neglect, or unauthorised modification by another practitioner.
- In the event of a medical emergency during treatment, the patient authorises the Dentist to provide immediate life-saving intervention. The clinic maintains a fully stocked emergency medical kit and is located within a five-minute ambulance response radius in Colombo.
- Disputes arising from this Quotation Estimate shall be resolved amicably. In the absence of resolution, matters shall be referred to the Sri Lanka Dental Association's grievance mechanism or the relevant court of competent jurisdiction in Colombo.
By signing below, the patient acknowledges that they have read, understood, and accepted all terms outlined in this Quotation Estimate. The patient confirms that the proposed treatment plan has been explained in clear terms by the treating Dentist and that all questions have been satisfactorily answered. The patient further confirms that no alternative treatment options have been withheld and that the decision to proceed is made voluntarily.
Patient SignatureName: Nimal Perera
Date: _______________ Authorised Dentist / Clinic Representative
Dr. Anjali Fernando, MDSc, FDS RCS
BrightSmile Dental Clinic, Colombo, Sri Lanka
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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