Quotation Estimate Orthodontist in Canada Montreal –Free Word Template Download with AI
1450 Rue Sainte-Catherine Ouest, Bureau 3200, Montreal, Quebec, Canada H3G 1Z4
Tel: (514) 555-0187 | Email: [email protected] | Reg. No.: Q-2019-48732
Quotation EstimatePrepared For
Patient: Jonathan R. Beauchamp
Address: 872 Avenue du Mont-Royal E, Montreal, QC H2N 1Y2, Canada
Phone: (514) 555-3321
Email: [email protected]
Date of Birth: March 14, 2001
Quotation Details
Quotation No.: QE-2025-00487
Date Issued: June 12, 2025
Valid Until: July 12, 2025
Referring Physician: Dr. A. Lavoie, General Dentist
Insurance Provider: Sun Life Financial (Plan #SL-88234)
Dear Mr. Beauchamp,
Thank you for visiting our orthodontic practice in Montreal. Following your comprehensive consultation and diagnostic evaluation conducted on June 5, 2025, we are pleased to present this Quotation Estimate outlining the full scope of orthodontic treatment recommended for your case. As a licensed Orthodontist registered with the Ordre des dentistes du Québec, I am committed to providing you with the highest standard of care in the greater Canada Montreal metropolitan area. This document serves as a detailed financial projection and is not a binding invoice. All prices are quoted in Canadian Dollars (CAD) and are subject to the terms and conditions listed below.
Itemized Treatment Plan & Pricing
| Item No. | Description of Orthodontic Service | Frequency | Unit Price (CAD) | Estimated Total (CAD) |
|---|---|---|---|---|
| 1 | Initial Comprehensive Consultation & Diagnostic Records (Panoramic X-ray, Cephalometric X-ray, Intraoral Photographs, Digital Impressions, Clinical Examination) | One-time | $350.00 | $350.00 |
| 2 | Custom-Fabricated Ceramic (Tooth-Coloured) Braces — Upper and Lower Arch, including bonding of brackets, archwires, and elastic ligatures | One-time | $4,200.00 | $4,200.00 |
| 3 | Monthly Adjustment Appointments (wire changes, elastic replacements, minor tooth movement corrections, occlusal adjustments) | 14 months | $125.00 | $1,750.00 |
| 4 | Interproximal Reduction (IPR) — Selective enamel stripping to create space for optimal tooth alignment (estimated 6 surfaces) | One-time | $180.00 | $180.00 |
| 5 | Removable Retainer (Hawley type) — Upper and Lower, custom-moulded to post-treatment occlusion | One-time | $450.00 | $450.00 |
| 6 | Post-Treatment Retention Follow-Up Visits (6-month intervals for the first 2 years, annual thereafter) | 5 visits | $75.00 | $375.00 |
| 7 | Emergency / Breakage Repairs (estimated allowance for 2 bracket re-bondings or wire adjustments during treatment) | As needed | $95.00 | $190.00 |
| 8 | Final Debonding, Polishing, and Post-Treatment Records (removal of all brackets, adhesive cleanup, final X-rays and photographs) | One-time | $275.00 | $275.00 |
| Estimated Grand Total (before insurance): | $7,770.00 | |||
| Estimated Insurance Coverage (Sun Life — 80% of allowable orthodontic fee): | -$5,419.00 | |||
| Estimated Patient Responsibility: | $2,351.00 | |||
Payment Options & Financing
This Quotation Estimate from our Montreal orthodontic clinic offers the following payment structures to accommodate your financial planning:
- Option A — Full Payment: Pay the total patient responsibility of $2,351.00 in a single transaction at the time of initial appliance placement. A 5% early-payment discount of $117.55 will be applied, reducing your balance to $2,233.45.
- Option B — Monthly Installments: Spread the patient responsibility over 14 monthly payments of $168.00, with no interest or additional fees. Payments are due on the 1st of each month via pre-authorized debit.
- Option C — Third-Party Financing: We partner with Sun Financial and Tangerine Financial to offer 0% interest financing over 12 to 24 months. A separate application and credit check are required.
Terms & Conditions
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the validity period expires, pricing may be adjusted to reflect current fee schedules of the Ordre des dentistes du Québec.
- All orthodontic services described herein will be performed by Dr. Marie-Claire Tremblay or under her direct supervision by a licensed orthodontic assistant at our clinic located in downtown Montreal, Canada.
- The estimated treatment duration of 14 months is a projection based on current clinical findings. Actual treatment time may vary by ±3 months depending on individual biological response, patient compliance with elastic wear, and any unforeseen clinical developments.
- Insurance reimbursement is subject to the terms of your Sun Life Financial policy. Our office will submit all claims directly to your insurer. Any discrepancy between the estimated coverage stated in this document and the actual reimbursement received by your insurer is the patient's financial responsibility.
- A non-refundable deposit of $500.00 is required to secure your treatment appointment and reserve materials. This deposit is applied toward the total treatment cost.
- Missed appointments must be rescheduled with a minimum of 48 hours' notice. Cancellations within 48 hours or no-shows will incur a $75.00 administrative fee, consistent with standard practice across orthodontic clinics in the Montreal, Quebec, Canada region.
- This Quotation Estimate does not constitute a guarantee of specific aesthetic or functional outcomes. Orthodontic treatment involves biological variables that cannot be fully predicted. A detailed informed consent form will be provided prior to the initiation of active treatment.
- All personal health information collected in connection with this orthodontic treatment plan is protected under the Personal Health Information Protection Act (PHIPA) of Quebec and the federal Privacy Act of Canada.
Acceptance & Authorization
By signing below, the patient (or legal guardian) acknowledges receipt of this Quotation Estimate, confirms understanding of the recommended orthodontic treatment plan, and authorizes the orthodontic practice to proceed with the services outlined above. The patient agrees to the payment option selected and the terms and conditions stated herein.
Patient / Legal Guardian Signature:
Name: Jonathan R. Beauchamp
Date: _________________________
Orthodontist / Authorized Representative:
Name: Dr. Marie-Claire Tremblay, DMD, MSc
Date: _________________________
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT