Quotation Estimate Orthodontist in Brazil Brasília –Free Word Template Download with AI
Orthodontist Professional Services — Brasília, Brazil
Official Estimate Document
Orthodontist Practice
Dr. Helena Vasconcelos, CRO-DF 12.847
Clínica Ortodôntica Brasília Prime
SHLS 706, Bloco B, Sala 412
Setor Hoteleiro Sul, Brasília — DF
CEP: 70390-100, Brazil
Tel: +55 (61) 3344-7820
Email: [email protected]
Client Information
Mr. Ricardo Almeida Santos
CPF: ***.482.***-09
QL 12, Lote 34, Casa 07
Setor Residencial Norte, Brasília — DF
CEP: 71510-000, Brazil
Tel: +55 (61) 99876-4321
Email: [email protected]
This Quotation Estimate is issued by the undersigned Orthodontist practice, Clínica Ortodôntica Brasília Prime, located in the Federal District of Brazil Brasília, to provide a comprehensive and itemized financial projection for the full orthodontic treatment plan recommended for the client identified above. All services described herein are to be performed at our clinic in the Setor Hoteleiro Sul district of Brasília, the capital city of Brazil, in strict compliance with the regulations established by the Conselho Regional de Odontologia do Distrito Federal (CRO-DF) and the broader guidelines of the Conselho Federal de Odontologia (CFO) of Brazil.
| Item | Description of Orthodontist Service | Qty | Unit Price (R$) | Subtotal (R$) |
|---|---|---|---|---|
| 01 | Initial Orthodontic Consultation & Diagnostic Evaluation (clinical exam, intraoral photographs, panoramic radiograph, cephalometric analysis, and digital study models) | 1 | 480.00 | 480.00 |
| 02 | Orthodontic Treatment Plan Formulation & Written Report (detailed plan with projected timelines, appliance options, and cost projections specific to the patient's malocclusion in Brasília) | 1 | 350.00 | 350.00 |
| 03 | Fixed Orthodontic Appliance Placement (metal or ceramic brackets, archwires, ligatures, and bonding on all indicated teeth) | 1 | 3,200.00 | 3,200.00 |
| 04 | Monthly Orthodontist Adjustment Visits (wire changes, elastic adjustments, bracket re-bonding if necessary) — estimated 22 months of treatment | 22 | 280.00 | 6,160.00 |
| 05 | Interproximal Reduction (IPR) / Enameloplasty (selective enamel trimming to resolve minor crowding, performed by the Orthodontist during adjustment sessions) | 1 | 650.00 | 650.00 |
| 06 | Removable Retainer Fabrication (Hawley or Essix type, upper and lower arches, to be delivered upon appliance removal) | 2 | 420.00 | 840.00 |
| 07 | Post-Treatment Orthodontic Follow-Up (3, 6, 12, and 24-month post-retainer check-ups to ensure stability of the corrected occlusion in the Brasília patient population) | 4 | 180.00 | 720.00 |
| 08 | Emergency Orthodontist Appointments (broken bracket, poking wire, or urgent appliance repair) — included up to 3 visits during treatment | 3 | 150.00 | 450.00 |
| 09 | Additional Radiographic Imaging (periapical or CBCT scans if clinically indicated during the course of treatment in Brasília) | 2 | 320.00 | 640.00 |
| 10 | Professional Dental Hygiene & Fluoride Application (bi-monthly during active orthodontic treatment to maintain oral health under the Orthodontist's supervision) | 11 | 210.00 | 2,310.00 |
| TOTAL ESTIMATED COST OF ORTHODONTIST TREATMENT | R$ 15,800.00 | |||
1. This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, prices may be adjusted to reflect current market conditions for orthodontic materials and professional fees in Brasília, Brazil.
2. A non-refundable deposit of twenty percent (20%) of the total estimated amount (R$ 3,160.00) is required to schedule the initial Orthodontist consultation and reserve the treatment slot at our Brasília clinic.
3. The remaining balance may be paid in monthly installments aligned with the Orthodontist adjustment visit schedule, or in full upon completion of active treatment. Installment payments shall be due on the 5th of each month.
4. Payment methods accepted: bank transfer (TED/PIX), credit card (up to 12 installments), or cash. All transactions are processed in Brazilian Reais (BRL) in accordance with Brazilian financial regulations.
5. This Quotation Estimate is a financial projection based on the current clinical findings. The final cost may vary if additional orthodontic procedures become necessary during treatment, in which case a supplementary Quotation Estimate will be issued and must be approved in writing by the client before any additional work commences.
6. The Orthodontist reserves the right to modify the treatment plan if clinical progress in Brasília deviates from the projected timeline. Any such modifications will be communicated transparently to the patient.
7. This document does not constitute a binding contract. A formal treatment agreement, signed by both the Orthodontist and the client, will be executed at the time of the initial consultation in Brasília, Brazil.
8. All orthodontic services are covered by the professional liability insurance of Dr. Helena Vasconcelos, registered with CRO-DF, and comply with all sanitary and ethical standards mandated by the Brazilian Federal Council of Dentistry.
Please be advised that the estimated treatment duration of twenty-two (22) months is based on the severity of the malocclusion identified during the preliminary evaluation. Individual biological responses may cause the actual timeline to vary by two to four months in either direction. The Orthodontist in Brasília will provide updated projections at each monthly adjustment visit.
Client is responsible for maintaining proper oral hygiene throughout the orthodontic treatment period. Failure to attend scheduled Orthodontist appointments in Brasília may result in extended treatment duration and additional costs not covered by this Quotation Estimate.
This Quotation Estimate is prepared exclusively for the named client and may not be transferred to a third party without prior written authorization from the Orthodontist practice.
Dr. Helena VasconcelosOrthodontist — CRO-DF 12.847
Clínica Ortodôntica Brasília Prime
Brasília — DF, Brazil Mr. Ricardo Almeida Santos
Client / Patient
CPF: ***.482.***-09
Brasília — DF, Brazil ⬇️ Download as DOCX Edit online as DOCX
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