Quotation Estimate Orthodontist in Brazil Rio de Janeiro –Free Word Template Download with AI

This Quotation Estimate is issued by our Orthodontist practice located in the heart of Brazil, Rio de Janeiro, and provides a comprehensive financial projection for the complete orthodontic treatment plan recommended following the initial clinical evaluation. All prices listed herein are expressed in Brazilian Reais (BRL) and include applicable taxes as mandated by the municipal and state regulations of Rio de Janeiro. This document serves as a formal Quotation Estimate and does not constitute a binding contract until both parties affix their signatures at the conclusion of this document.

Based on the clinical assessment performed by our Orthodontist specialist on 10 June 2025, the following treatment protocol has been designed for the patient. The Quotation Estimate below itemizes each phase of the orthodontic intervention, including diagnostic imaging, appliance fabrication, monthly adjustment sessions, and post-treatment retention, all delivered at our clinic in Copacabana, Rio de Janeiro, Brazil.

The total Quotation Estimate of R$ 19,940.00 may be settled according to the following options, all of which are subject to the financial policies of our Orthodontist clinic in Rio de Janeiro, Brazil:

• Option A – Full Payment: 100% of the total amount due within 7 business days of signing. A 5% discount (R$ 997.00) will be applied, resulting in a final amount of R$ 18,943.00.
• Option B – Installment Plan: 20% down payment (R$ 3,988.00) at the time of signing, followed by 18 equal monthly installments of R$ 947.56, payable via direct debit (débito automático) or PIX transfer on the 5th of each month.
• Option C – Dental Insurance (Plano Odontológico): If the patient holds a valid orthodontic coverage plan recognized in the state of Rio de Janeiro, the applicable co-payment and deductible will be deducted from this Quotation Estimate. The patient is responsible for presenting the insurance card and authorization number prior to the first appointment.

• This Quotation Estimate is valid for 30 calendar days from the date of issue. After this period, prices may be revised to reflect changes in material costs, municipal tax rates in Rio de Janeiro, or the Orthodontist's fee schedule.
• The estimated treatment duration of 18 months is a clinical projection. The actual timeline may vary by ±3 months depending on the patient's biological response, compliance with elastic wear, and attendance at all scheduled appointments.
• All services are to be performed exclusively at our clinic located at Av. Atlântica, 1250, Copacabana, Rio de Janeiro, RJ, Brazil. No services will be rendered at satellite locations.
• Prices include all applicable taxes (ISS – Imposto Sobre Serviços, as regulated by the Prefeitura do Rio de Janeiro). No additional municipal or state fees will be charged beyond those listed.
• Any additional orthodontic procedures not foreseen in this Quotation Estimate (e.g., surgical orthodontics, additional extractions, or extended retention) will be quoted separately in a supplementary document.

In the event the patient elects to discontinue treatment prior to completion, the Orthodontist will provide a written assessment of the clinical status. A pro-rata refund of unused monthly installments will be issued within 30 business days, less any non-recoverable material costs already incurred. The initial diagnostic fee (Item 1) and treatment plan fee (Item 2) are non-refundable once the clinical evaluation has been completed. This policy is in accordance with the Consumer Protection Code (Código de Defesa do Consumidor – Lei 8.078/1990) of Brazil.

By signing below, the patient acknowledges that this Quotation Estimate has been reviewed, all terms explained by the Orthodontist, and the scope of services to be performed in Rio de Janeiro, Brazil is understood and accepted. This signature authorizes the commencement of the orthodontic treatment plan as described herein.