Quotation Estimate Dentist in Vietnam Ho Chi Minh City –Free Word Template Download with AI
Professional Dentist Services — Vietnam Ho Chi Minh City
VALID QUOTATION
Golden Smile Dental Clinic128 Nguyen Hue Boulevard, District 1
Ho Chi Minh City, Vietnam 700000
Tel: +84 28 3822 4567
Email: [email protected]
License No: 2019-DMC-0456 Quotation No: QTE-2025-0783
Date Issued: 15 June 2025
Valid Until: 15 July 2025
Prepared By: Dr. Nguyen Thi Lan
Position: Lead Dentist & Clinic Director CLIENT INFORMATION
| Field | Details |
|---|---|
| Client Name: | Mr. James R. Thompson |
| Passport / ID No: | GB-558291047 |
| Address: | 45 Le Duan Street, District 3, Ho Chi Minh City, Vietnam |
| Contact Number: | +84 90 123 4567 |
| Email: | [email protected] |
| Insurance Provider: | AXA Vietnam (Policy No: AXA-VN-2024-88213) |
The following Quotation Estimate outlines the comprehensive Dentist treatment plan recommended by our clinical team in Vietnam Ho Chi Minh City. All procedures will be performed by licensed and internationally trained dental professionals at our state-of-the-art facility. Prices are quoted in Vietnamese Dong (VND) and US Dollars (USD) for the convenience of international clients.
| No. | Dentist Service / Procedure | Quantity | Unit Price (VND) | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dental Examination & Digital X-Ray (Panoramic + Periapical) | 1 session | 1,200,000 | $50.00 | $50.00 |
| 2 | Professional Dental Cleaning & Scaling (Ultrasonic + Airflow Polishing) | 1 session | 2,500,000 | $105.00 | $105.00 |
| 3 | Root Canal Treatment (Upper Molar, Single Root) | 2 teeth | 8,500,000 | $355.00 | $710.00 |
| 4 | Porcelain Crown (Zirconia) — Post Root Canal Restoration | 2 units | 12,000,000 | $500.00 | $1,000.00 |
| 5 | Composite Resin Filling (Tooth #14, Moderate Cavity) | 1 tooth | 3,000,000 | $125.00 | $125.00 |
| 6 | Full Mouth Intraoral Scan (3D Digital Impression for Records) | 1 session | 1,500,000 | $63.00 | $63.00 |
| 7 | Follow-Up Consultation & Treatment Review (2 visits included) | 2 visits | 500,000 | $21.00 | $42.00 |
| 8 | Emergency Dentist Visit (If required within 30 days of treatment) | 1 visit | 1,000,000 | $42.00 | $42.00 |
Subtotal: $2,137.00
VAT (10% — Vietnam Standard Rate): $213.70
Insurance Coverage (AXA Vietnam, 70%): −$1,495.90
GRAND TOTAL (Client Payable): $854.80 / 20,515,200 VND
TERMS AND CONDITIONS OF THIS QUOTATION ESTIMATE- 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, exchange rate fluctuations, or updated Dentist service fees in Vietnam Ho Chi Minh City.
- All Dentist procedures listed in this Quotation Estimate will be performed at our clinic located in District 1, Ho Chi Minh City, Vietnam. The clinic operates Monday through Saturday, from 08:00 to 18:00, and is closed on Vietnamese public holidays.
- The total treatment timeline for the procedures outlined above is estimated at four (4) to six (6) weeks, depending on healing periods required between the root canal treatment and the placement of zirconia crowns. Our Dentist team will schedule all appointments in advance and coordinate with the client's availability.
- Payment may be made in Vietnamese Dong (VND), US Dollars (USD), or via bank transfer to our registered account in Ho Chi Minh City. A 50% deposit is required to confirm the treatment schedule, with the remaining balance due upon completion of the final procedure.
- Insurance claims will be processed directly by our clinic's billing department in coordination with AXA Vietnam. The client is responsible for any co-payment or services not covered under the policy terms. The Quotation Estimate reflects the estimated insurance deduction; actual reimbursement may vary.
- All Dentist treatments are covered by a warranty period of twelve (12) months from the date of final procedure completion. This warranty covers material defects and procedural complications but does not cover damage resulting from trauma, neglect, or failure to attend scheduled follow-up appointments.
- Our clinic in Vietnam Ho Chi Minh City is fully licensed by the Ho Chi Minh City Department of Health. All Dentist practitioners hold valid medical licenses and have completed international continuing education certifications. Sterilization protocols follow WHO and Vietnamese Ministry of Health standards.
- Any additional procedures identified during treatment that are not included in this Quotation Estimate will require written client approval before proceeding. A supplementary Quotation Estimate will be issued for any such additional services.
- This Quotation Estimate does not constitute a binding contract until signed and accepted by both parties. By signing below, the client acknowledges understanding of all terms and authorizes the Dentist team at Golden Smile Dental Clinic to proceed with the recommended treatment plan.
Prepared By (Dentist / Clinic Representative)
Dr. Nguyen Thi Lan
Lead Dentist & Clinic Director
Golden Smile Dental Clinic, Ho Chi Minh City
Accepted By (Client)
Mr. James R. Thompson
Date: _______________
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