Quotation Estimate Orthodontist in Belgium Brussels –Free Word Template Download with AI
Orthodontist Treatment Plan & Financial Estimate
Belgium Brussels — Official Quotation DocumentOrthodontist Practice
Dr. Catherine Van den Berghe, DMD, Orthodontist
Brussels Orthodontic Centre
142 Avenue Louise, 1050 Brussels, Belgium
Tel: +32 2 512 3456
Email: [email protected]
VAT No: BE 0765.432.109
IBAN: BE68 5390 0754 7034
Quotation Details
Quotation No: QTE-2025-0847
Date Issued: 14 June 2025
Valid Until: 14 September 2025
Currency: EUR (€)
Prepared By: Dr. C. Van den Berghe
Referral Source: Dr. M. Peeters, General Dentist
Client Information
Name: Mr. Julien De Smet
Address: 28 Rue de la Loi, 1040 Brussels, Belgium
Phone: +32 475 678 901
Email: [email protected]
RIZIV/INAMI No: 854.321.098.76
Insurance: AXA Belgium — Supplementary Dental Plan
This Quotation Estimate has been prepared by our Orthodontist team at the Brussels Orthodontic Centre to provide Mr. Julien De Smet with a comprehensive and transparent financial overview of the proposed orthodontic treatment. As a registered Orthodontist practice operating in Belgium Brussels, we adhere to the professional standards set by the Belgian Orthodontic Society (SBOB) and the regulatory framework of the Brussels-Capital Region. This document outlines all anticipated costs associated with the full course of orthodontic care, including diagnostic procedures, active treatment, and retention phases.
| Item No. | Description of Orthodontist Service | Frequency | Unit Price (EUR) | Estimated Total (EUR) |
|---|---|---|---|---|
| 01 | Initial Orthodontist Consultation & Comprehensive Diagnostic Assessment (intraoral examination, clinical photographs, digital records) | One-time | €120.00 | €120.00 |
| 02 | Full Panoramic Radiograph (OPG) & Cephalometric X-ray Analysis | One-time | €85.00 | €85.00 |
| 03 | Digital Intraoral Scan (iTero) & 3D Treatment Simulation | One-time | €150.00 | €150.00 |
| 04 | Placement of Fixed Ceramic Braces (Upper & Lower Arch) — Orthodontist Active Treatment | One-time | €2,800.00 | €2,800.00 |
| 05 | Monthly Orthodontist Adjustment & Progression Appointments (wire changes, elastic adjustments, bracket re-cements) | 18 months | €95.00 | €1,710.00 |
| 06 | Interproximal Reduction (IPR) & Minor Orthodontic Tooth Movement (if required during treatment) | As needed | €45.00 | €270.00 |
| 07 | Removal of Fixed Appliances & Final Bonding of Retainers (upper & lower) | One-time | €250.00 | €250.00 |
| 08 | Removable Retainer Fabrication (Essix type, 2 sets) & Annual Retention Check-ups (3 years) | 3 years | €180.00 | €540.00 |
| 09 | Emergency Orthodontist Visits (broken bracket, wire irritation, appliance repair) — estimated allowance | Up to 3 visits | €60.00 | €180.00 |
| 10 | Post-Treatment Panoramic Radiograph & Final Orthodontist Evaluation Report | One-time | €75.00 | €75.00 |
| Subtotal (All Orthodontist Services) | €6,280.00 |
| VAT (21% — Belgian Standard Rate) | €1,318.80 |
| Grand Total (Quotation Estimate) | €7,598.80 |
| Estimated RIZIV/INAMI Reimbursement (Orthodontist category) | −€1,240.00 |
| Estimated AXA Supplementary Dental Reimbursement | −€1,800.00 |
| Estimated Patient Out-of-Pocket Cost | €4,558.80 |
- Payment Schedule: The total Quotation Estimate amount (excluding insurance reimbursements) shall be payable in monthly instalments of €380.00 over the 18-month active treatment period, with an initial deposit of €500.00 due upon acceptance of this Quotation Estimate and prior to the placement of orthodontic appliances.
- Insurance Reimbursement: The patient is responsible for submitting all invoices and supporting documentation to RIZIV/INAMI and AXA Belgium for reimbursement. Our Orthodontist practice in Belgium Brussels will provide all necessary medical certificates, treatment reports, and itemised invoices required for the insurance claim process.
- Quotation Validity: This Quotation Estimate is valid for a period of 90 days from the date of issue. Should the patient wish to proceed after the validity period, the Orthodontist practice reserves the right to re-evaluate and issue a revised Quotation Estimate reflecting any changes in material costs or Belgian regulatory fee structures.
- Cancellation Policy: In the event that the patient decides to discontinue orthodontic treatment after the initial placement of appliances, a cancellation fee of 15% of the remaining Quotation Estimate balance will apply, in accordance with Belgian consumer protection regulations applicable to healthcare services in Brussels.
- Warranty: The Orthodontist practice guarantees the quality of all orthodontic appliances and bonding materials for a period of 12 months from the date of placement. Any defects in materials or workmanship will be repaired at no additional cost to the patient.
- Regulatory Compliance: This Quotation Estimate and all associated orthodontic services are provided in full compliance with the Belgian Law on the Practice of Medicine (1994), the Brussels-Capital Region healthcare regulations, and the ethical code of the Belgian Orthodontic Society. The patient has the right to request a second opinion from any other registered Orthodontist in Belgium Brussels at no obligation.
- Data Protection: All patient data processed in connection with this Quotation Estimate and subsequent treatment are handled in accordance with the Belgian Data Protection Act and the EU General Data Protection Regulation (GDPR). Data will be stored securely at the Brussels Orthodontic Centre and will not be shared with third parties except as required by Belgian law or insurance reimbursement procedures.
By signing below, the patient acknowledges receipt of this Quotation Estimate and confirms that the Orthodontist has explained the proposed treatment plan, associated costs, and alternative options in a clear and understandable manner. The patient agrees to the payment terms and conditions outlined in this document.
| Patient Signature | Orthodontist Signature |
|---|---|
|
Name: Mr. Julien De Smet Date: ____________________ Signature: ____________________ |
Name: Dr. Catherine Van den Berghe, DMD Date: ____________________ Signature: ____________________ |
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