Quotation Estimate Orthodontist in China Beijing –Free Word Template Download with AI
Capital Orthodontic Center • No. 88 Jianguo Road, Chaoyang District, Beijing, China 100022
1. Client Information
| Field | Details |
|---|---|
| Patient Name | Mr. Zhang Yiming |
| Address | Apartment 1204, Building 6, Haidian District, Beijing, China |
| Phone | +86 138 0012 5678 |
| Insurance Provider | Beijing Municipal Health Insurance (BMHI) — Policy No. BJH-2025-77812 |
| Referring Physician | Dr. Chen Xiaofeng, General Dentistry, Beijing Stomatological Hospital |
2. Scope of Orthodontist Services
This Quotation Estimate has been prepared by our licensed Orthodontist team at Capital Orthodontic Center, located in the heart of China Beijing, to provide a comprehensive and transparent breakdown of all anticipated costs associated with the recommended orthodontic treatment plan. The following services have been identified following a full clinical examination, panoramic radiography (OPG), intraoral digital scanning, and cephalometric analysis conducted on 10 June 2025.
As a specialized Orthodontist practice operating in China Beijing, we adhere to the national standards set forth by the National Health Commission of the People's Republic of China and the Chinese Stomatological Association guidelines for orthodontic care. All procedures outlined in this Quotation Estimate will be performed by board-certified Orthodontist professionals with a minimum of ten years of clinical experience in the Beijing metropolitan area.
3. Itemized Cost Breakdown
| # | Service / Procedure | Frequency | Unit Price (CNY) | Total (CNY) | Notes |
|---|---|---|---|---|---|
| 1 | Initial Consultation & Diagnostic Workup (OPG, CBCT, digital impressions, photos) | One-time | 1,200.00 | 1,200.00 | Includes treatment planning |
| 2 | Comprehensive Orthodontic Treatment — Ceramic Self-Ligating Braces (upper & lower arches) | 18 months | 28,000.00 | 28,000.00 | Includes all bracket placements |
| 3 | Monthly Adjustment & Wire Changes (Orthodontist visit) | 18 visits | 800.00 | 14,400.00 | Approx. 4-week intervals |
| 4 | Interproximal Reduction (IPR) — selective enamel stripping | As needed | 150.00 | 1,200.00 | Estimated 8 surfaces |
| 5 | Orthodontic Elastics & Auxiliary Appliances (monthly supply) | 18 months | 200.00 | 3,600.00 | Includes power chains, rubber bands |
| 6 | Debonding & Finishing (removal of all brackets, polishing) | One-time | 2,500.00 | 2,500.00 | Includes occlusal adjustment |
| 7 | Fixed Retainers (upper & lower) + Removable Retainers (Hawley type) | One-time | 3,200.00 | 3,200.00 | Includes 2 replacement sets |
| 8 | Post-Treatment Review Visits (3, 6, 12, 24 months) | 4 visits | 500.00 | 2,000.00 | Retainer check & adjustments |
| 9 | Emergency Orthodontist Appointment (if required during treatment) | Up to 2 | 600.00 | 1,200.00 | Broken bracket, wire irritation |
| 10 | Digital Progress Monitoring & Patient Portal Access | 18 months | 300.00 | 300.00 | Cloud-based records, China Beijing clinic |
| GRAND TOTAL (CNY) | 57,600.00 | ||||
| Estimated BMHI Reimbursement (approx. 40%) | −23,040.00 | ||||
| PATIENT RESPONSIBLE AMOUNT (CNY) | 34,560.00 | ||||
4. Payment Schedule
In accordance with standard practice at our Orthodontist clinic in China Beijing, the patient responsible amount of CNY 34,560.00 may be settled through the following installment plan:
| Installment | Due Date | Amount (CNY) |
|---|---|---|
| Deposit (upon signing this Quotation Estimate) | 20 June 2025 | 10,000.00 |
| 2nd Payment (Month 3) | 20 September 2025 | 8,000.00 |
| 3rd Payment (Month 6) | 20 December 2025 | 8,000.00 |
| 4th Payment (Month 9) | 20 March 2026 | 8,560.00 |
5. Terms and Conditions
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiry date, pricing may be subject to revision based on material cost fluctuations in the China Beijing dental supply market.
- All services will be performed by a licensed Orthodontist or a supervised orthodontic assistant at our facility in Chaoyang District, Beijing. The treating Orthodontist will be Dr. Liang Wei or a designated associate of equivalent qualification.
- The total treatment duration is estimated at eighteen (18) months. Actual duration may vary by ±3 months depending on individual biological response, patient compliance with elastics wear, and any unforeseen clinical adjustments.
- Should the patient discontinue treatment before completion, a pro-rata charge for unused appointments and materials will apply as detailed in the separate Service Agreement.
- Insurance claims under the Beijing Municipal Health Insurance scheme must be submitted within ninety (90) days of each service date. Our front-desk team in China Beijing will assist with all documentation.
- Prices are quoted in Chinese Yuan (CNY) and are inclusive of all applicable Value Added Tax (VAT) at the current rate of 6% for medical services in Beijing.
- This Quotation Estimate does not constitute a binding contract. A formal Treatment Consent Form and Service Agreement must be signed prior to the commencement of any orthodontic procedure.
- Any additional procedures not listed herein (e.g., extractions, periodontal therapy, restorative work) will be quoted separately and require written patient approval before execution.
6. Acceptance and Authorization
By signing below, the patient acknowledges receipt of this Quotation Estimate for Orthodontist services at Capital Orthodontic Center, China Beijing, and agrees to the terms outlined above. This signature authorizes the Orthodontist team to proceed with the initial diagnostic phase upon receipt of the deposit.
Patient SignatureName: Zhang Yiming
Date: ____________________ Orthodontist / Authorized Representative
Name: Dr. Liang Wei
Date: ____________________ ⬇️ Download as DOCX Edit online as DOCX
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