Quotation Estimate Dentist in United States Los Angeles –Free Word Template Download with AI

Terms, Conditions & Patient Acknowledgment

1. This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date of July 12, 2025, a revised estimate may be required to reflect any changes in material costs or fee adjustments.
2. All dental procedures listed herein will be performed by licensed dentists at our Los Angeles, California facility in compliance with the California Business and Professions Code and the regulations of the California Dental Board.
3. Payment is due at the time of service unless a pre-arranged payment plan has been established in writing. We accept all major credit cards, HSA/FSA cards, and offer in-house financing through CareCredit and Sunbit for qualified patients.
4. Insurance claims will be submitted directly by our billing office. The patient is responsible for any co-pays, deductibles, or non-covered services as determined by their insurance carrier. We are not responsible for insurance policy changes or claim denials.
5. A 24-hour cancellation notice is required for all scheduled dental appointments. Late cancellations or no-shows may incur a fee of $150.00, which will be added to this estimate if applicable.
6. This estimate does not constitute a guarantee of specific clinical outcomes. The treating dentist reserves the right to modify the treatment plan if additional procedures become necessary during the course of treatment, with prior written consent from the patient.
7. All patient records, radiographic images, and treatment documentation will be maintained in accordance with HIPAA regulations and California Health and Safety Code Section 123105.
8. By signing below, the patient acknowledges receipt of this Quotation Estimate, understands the projected costs, and authorizes the dental team to proceed with the outlined treatment plan at the Westside Smile Dental Group practice in Los Angeles, United States.