Quotation Estimate Dentist in Thailand Bangkok –Free Word Template Download with AI
Professional Dental Care Services | Licensed by the Thai Ministry of Public Health
Issued By:Bangkok Smile Dental Clinic
88/12 Sukhumvit Road, Soi 24
Klongtoey, Klongtoey, Bangkok 10110
Thailand Bangkok
Tel: +66 (0) 2 255 8899
Email: [email protected] Quotation Reference: QTE-2025-BKK-04782
Date of Issue: 15 June 2025
Valid Until: 15 July 2025
Currency: Thai Baht (THB) Client / Patient Information
| Patient Name: Mr. James R. Anderson | Patient ID: BKK-PT-2025-3391 |
| Address: 45/7 Thonglor Road, Watthana, Bangkok 10110, Thailand | Contact: +66 (0) 89 555 1234 |
| Insurance Provider: AIA Thailand (Policy No. AIA-88234567) | Referring Dentist: Dr. Sarah Mitchell, London UK |
| No. | Service Description | Procedure Code | Qty | Unit Price (THB) | Subtotal (THB) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dental Examination & Digital X-Ray (Panoramic + Periapical) Full oral assessment by a licensed Dentist in Thailand Bangkok, including periodontal charting, caries detection, and radiographic imaging for treatment planning. |
DX-101 / DX-102 | 1 | 2,500.00 | 2,500.00 |
| 2 | Ultrasonic Scaling & Polishing (Full Mouth) Professional prophylaxis performed by a certified dental hygienist under the supervision of the lead Dentist. Includes removal of supragingival and subgingival calculus, followed by fluoride varnish application. |
SC-201 | 1 | 3,200.00 | 3,200.00 |
| 3 | Composite Resin Restorations (Anterior & Posterior) Placement of tooth-coloured composite fillings using 3M Z350 XT material. Includes cavity preparation, bonding, layering, and polishing. Performed by a senior Dentist with over 15 years of experience in Thailand Bangkok. |
RS-301 | 4 | 3,800.00 | 15,200.00 |
| 4 | Root Canal Treatment (Single-Root Molar, Upper Right #16) Complete endodontic therapy including access cavity, canal instrumentation, obturation with gutta-percha, and temporary restoration. Conducted under local anaesthesia by a specialist endodontist at our Thailand Bangkok facility. |
RC-401 | 1 | 12,500.00 | 12,500.00 |
| 5 | Full-Ceramic Crown (E.max Zirconia, Upper Right #16) Custom-fabricated all-ceramic crown milled from premium zirconia block. Includes impression taking, temporary crown placement, and final cementation. Designed and manufactured in-house at our Bangkok laboratory. |
CR-501 | 1 | 18,000.00 | 18,000.00 |
| 6 | Professional Teeth Whitening (In-Office, Zoom! System) Single-session LED-activated whitening treatment for up to 8 shades of improvement. Includes pre-treatment sensitivity management and post-treatment take-home whitening strips (2-week supply). |
WT-601 | 1 | 8,500.00 | 8,500.00 |
| 7 | Follow-Up Consultation & Post-Operative Review (2 Sessions) Two scheduled follow-up appointments with the treating Dentist to assess healing, verify crown fit, and provide aftercare guidance. Includes one complimentary re-polish. |
FC-701 | 2 | 800.00 | 1,600.00 |
| Subtotal: | 61,500.00 THB | ||||
| VAT (7%): | 4,305.00 THB | ||||
| TOTAL QUOTATION ESTIMATE AMOUNT: | 65,805.00 THB | ||||
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiry date, pricing may be subject to revision based on material costs and exchange rate fluctuations applicable in Thailand Bangkok.
- Payment is due in full prior to the commencement of any invasive dental procedure. We accept bank transfer (Thai Baht), major credit cards (Visa, Mastercard, Amex), and cash. A 20% deposit is required to secure the appointment slot.
- All dental treatments will be performed by a licensed Dentist or dental specialist registered with the Thai Dental Council. The lead treating Dentist for this case is Dr. Ananya Chaiyaporn, DDS, MSc (Endodontics), with 18 years of clinical practice in Thailand Bangkok.
- Insurance claims: Our clinic will prepare all necessary documentation for submission to AIA Thailand. The patient is responsible for any co-payment or deductible amounts not covered by the insurance policy. Pre-authorization must be obtained before treatment begins.
- Warranty: All ceramic crowns carry a 24-month warranty against manufacturing defects. Composite restorations carry a 12-month warranty. Warranty does not cover damage from trauma, bruxism, or failure to attend scheduled follow-up appointments.
- Cancellation policy: Appointments cancelled with less than 48 hours' notice will incur a 50% fee of the scheduled procedure. No-shows will be charged the full procedure fee.
- This Quotation Estimate does not constitute a binding contract until signed and accepted by both parties. The clinic reserves the right to modify the treatment plan if clinical findings during the procedure necessitate additional or alternative interventions, in which case a revised Quotation Estimate will be presented for approval before proceeding.
- All patient data and medical records are handled in strict compliance with Thailand's Personal Data Protection Act (PDPA) B.E. 2562 (2019).
Prepared By (Clinic Representative)
Dr. Ananya Chaiyaporn, DDS, MSc
Lead Dentist & Clinic Director
Bangkok Smile Dental Clinic, Thailand Bangkok
Signature & Date
Accepted By (Patient)
Mr. James R. Anderson
Patient / Client
Signature & Date
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