Quotation Estimate Orthodontist in Australia Melbourne –Free Word Template Download with AI
Orthodontic Treatment Services — Australia Melbourne
Practice Details
Dr. Sarah Mitchell, AO
Lead Orthodontist & Director
Melbourne Orthodontic Centre
Level 4, 285 Collins Street
Victoria 3000, Australia Melbourne
ABN: 48 215 673 901
Phone: +61 3 9655 4200
Email: [email protected]
Client Details
Mr. James A. Thornton
142 Albert Street
South Yarra VIC 3141
Australia Melbourne
Phone: +61 412 783 556
Email: [email protected]
Medicare No: 8012 3456 7890
This Quotation Estimate has been prepared by Melbourne Orthodontic Centre, a registered and accredited Orthodontist practice located in the heart of Australia Melbourne, to provide Mr. James A. Thornton with a comprehensive, itemised financial projection for the proposed orthodontic treatment plan. As your dedicated Orthodontist in Australia Melbourne, we are committed to full transparency regarding all costs, timelines, and clinical expectations associated with your care. This Quotation Estimate reflects current Australian Health Practitioner Regulation Agency (AHPRA) fee schedules, private health insurance rebate structures, and the specific clinical requirements identified during your initial consultation on 28 May 2025.
Following a full intraoral examination, panoramic radiograph (OPG), cephalometric analysis, and digital impression scan performed at our Australia Melbourne clinic, the following orthodontic intervention has been recommended. As your treating Orthodontist, Dr. Mitchell has determined that a fixed appliance protocol combined with adjunctive periodontal maintenance is clinically indicated to correct Class II malocclusion, anterior crowding, and mild midline deviation.
| Item No. | Description of Orthodontic Service | Frequency | Unit Price (AUD) | Estimated Total (AUD) |
|---|---|---|---|---|
| 1 | Initial Consultation, Digital Records & Treatment Planning (Orthodontist assessment) | One-off | $320.00 | $320.00 |
| 2 | Full Intraoral & Extraoral Photography, OPG, CBCT Scan | One-off | $410.00 | $410.00 |
| 3 | Fixed Metal Braces — Bonding, Adjustment & Debonding (Full Arch, Upper & Lower) | 14 months | $4,850.00 | $4,850.00 |
| 4 | Monthly Orthodontic Adjustment Appointments (Australia Melbourne clinic) | 14 visits | $185.00 | $2,590.00 |
| 5 | Interproximal Reduction (IPR) & Composite Resin Contouring | As required | $650.00 | $650.00 |
| 6 | Removable Retainer (Hawley Type) — Upper & Lower | One-off | $520.00 | $520.00 |
| 7 | Post-Treatment Retention Review (6-monthly, Year 1 & Year 2) | 4 visits | $140.00 | $560.00 |
| 8 | Emergency / Urgent Orthodontist Appointment (Bracket Re-bond, Wire Adjustment) | Up to 2 visits | $160.00 | $320.00 |
| TOTAL ESTIMATED COST (Inclusive of GST @ 10%) | $10,220.00 | |||
The total Quotation Estimate amount of $10,220.00 AUD may be settled through the following options, as determined by the patient in consultation with the Orthodontist practice in Australia Melbourne:
- Full Payment at Commencement: A 10% discount (approximately $1,022.00) is applied when the full Quotation Estimate balance is paid prior to appliance bonding.
- Interest-Free Instalment Plan: The total may be divided into 14 equal monthly instalments of $730.00, aligned with each adjustment appointment. No interest or additional fees apply.
- Private Health Insurance Rebate: Where the patient holds a private health insurance policy with an orthodontic extras cover, the Orthodontist in Australia Melbourne will submit a claim on the patient's behalf. The patient is responsible for any gap between the insurer's rebate and the Quotation Estimate amount. Please note that most Australian insurers impose a lifetime orthodontic benefit cap, typically ranging from $1,500 to $3,000 AUD.
- Medicare: Orthodontic treatment for cosmetic purposes is not covered under the Australian Medicare Benefits Schedule. This Quotation Estimate therefore reflects the full out-of-pocket cost to the patient, less any applicable private insurance rebate.
- This Quotation Estimate is valid for a period of ninety (90) days from the date of issue. After this period, the Orthodontist practice reserves the right to revise fees in accordance with current Australian pricing standards.
- All orthodontic services described in this Quotation Estimate will be performed by or under the direct clinical supervision of a registered Orthodontist holding a Specialist Registration with the Australian Dental Association (ADA) and the Royal Australian and New Zealand College of Dentists (RANZCD).
- The patient acknowledges that orthodontic treatment outcomes, while highly predictable, are subject to individual biological variation. The Orthodontist in Australia Melbourne will provide regular progress updates at each scheduled appointment.
- Appointment cancellations must be made no fewer than forty-eight (48) hours in advance. Late cancellations or no-shows may incur a fee of $80.00 AUD, which will be added to the Quotation Estimate balance.
- This Quotation Estimate does not constitute a binding contract until signed and returned by the patient. The Orthodontist practice in Australia Melbourne will not commence treatment until a signed acceptance and the initial deposit (where applicable) have been received.
- All clinical records, radiographs, and digital scans generated during the course of treatment remain the property of the Orthodontist practice. The patient is entitled to a copy of their records upon written request, in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles.
By signing below, the patient confirms that they have received, read, and understood this Quotation Estimate for orthodontic treatment provided by the Orthodontist at Melbourne Orthodontic Centre, Australia Melbourne. The patient agrees to the clinical plan, the estimated costs, the payment terms, and the conditions outlined in this document. The patient further acknowledges that they have had the opportunity to ask questions and seek a second opinion from another Orthodontist if desired.
Patient Signature: ___________________________Name: Mr. James A. Thornton
Date: _______________ Orthodontist / Practice Representative: ___________________________
Name: Dr. Sarah Mitchell, AO
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT