Quotation Estimate Orthodontist in DR Congo Kinshasa –Free Word Template Download with AI
Orthodontist Professional Services — DR Congo Kinshasa
Document Ref: QTE-ORTHO-KIN-2025-0047 Issued By:Dr. Emmanuel Kabasele, DDS, MSc Orthodontics
Kinshasa Advanced Orthodontic Center
Avenue de la Paix, Commune de Gombe
Kinshasa, Democratic Republic of Congo (DR Congo)
Tel: +243 81 234 5678
Email: [email protected] Quotation Estimate Details:
Date of Issue: 15 June 2025
Valid Until: 15 July 2025
Currency: United States Dollar (USD)
Payment Terms: 50% Deposit / 50% Completion 1. Client Information
| Patient Name: | Mme. Patricia Mbuyi |
| Address: | Quartier Matonge, Commune de Lemba, Kinshasa, DR Congo |
| Contact Number: | +243 99 876 5432 |
| Referring Physician: | Dr. Jean-Pierre Tshibanda, General Dentist, Kinshasa |
This Quotation Estimate is prepared by our licensed Orthodontist practice located in the heart of DR Congo Kinshasa to provide a comprehensive breakdown of all planned orthodontic treatments, diagnostic procedures, and associated materials. The following services have been recommended following a full clinical examination, panoramic radiography, and intraoral digital scanning conducted on 10 June 2025 at our clinic in the Gombe district of Kinshasa.
3. Itemized Quotation Estimate Breakdown| Item No. | Description of Orthodontist Service | Qty | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|
| 01 | Initial Comprehensive Orthodontic Consultation & Clinical Examination | 1 | 85.00 | 85.00 |
| 02 | Panoramic Radiograph (OPG) & Cephalometric Analysis | 1 | 65.00 | 65.00 |
| 03 | Digital Intraoral Scanning & 3D Treatment Planning | 1 | 120.00 | 120.00 |
| 04 | Pre-Orthodontic Periodontal Treatment (Scaling & Polishing) | 1 | 95.00 | 95.00 |
| 05 | Extraction of Supernumerary Teeth (Upper & Lower, 2 teeth) | 2 | 75.00 | 150.00 |
| 06 | Fixed Metal Braces — Full Arch (Upper & Lower) — Materials & Bonding | 1 | 1,450.00 | 1,450.00 |
| 07 | Monthly Orthodontist Adjustment Visits (Estimated 18 months of treatment) | 18 | 55.00 | 990.00 |
| 08 | Interproximal Reduction (IPR) — Selective Enamel Reduction | 1 | 110.00 | 110.00 |
| 09 | Removable Retainer (Hawley Type) — Upper & Lower | 2 | 85.00 | 170.00 |
| 10 | Post-Treatment Follow-Up & Retainer Adjustment (6 months) | 6 | 35.00 | 210.00 |
| 11 | Emergency Orthodontist Visit (Bracket/Archwire Repair) — Included | 3 | 0.00 | 0.00 |
| TOTAL QUOTATION ESTIMATE AMOUNT | 3,445.00 | |||
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, pricing may be subject to revision due to fluctuations in the exchange rate between the Congolese Franc (CDF) and the US Dollar, or changes in the cost of imported orthodontic materials.
- Payment Schedule: A non-refundable deposit of fifty percent (50%) of the total Quotation Estimate amount, amounting to USD 1,722.50, is due upon acceptance of this document. The remaining balance of USD 1,722.50 shall be payable in two equal installments: fifty percent (50%) at the midpoint of the treatment (month 9) and fifty percent (50%) upon completion of active orthodontic treatment and delivery of retainers.
- Accepted Payment Methods: Cash (USD), bank transfer to our account at BCC (Banque Commerciale du Congo) in Kinshasa, or mobile money via M-Pesa / Airtel Money. International wire transfers are accepted with a 3% processing surcharge.
- Treatment Duration: The estimated duration of active Orthodontist treatment is eighteen (18) months, subject to individual biological response. The Orthodontist in DR Congo Kinshasa reserves the right to extend or shorten the treatment period based on clinical progress observed during monthly adjustment visits.
- Patient Responsibilities: The patient agrees to attend all scheduled Orthodontist adjustment appointments at our clinic in Gombe, Kinshasa. Missed appointments must be rescheduled at least 48 hours in advance. Three (3) unexcused absences may result in a fee of USD 25.00 per missed visit.
- Warranty: All orthodontic appliances bonded by our Orthodontist practice carry a six-month warranty against manufacturing defects. Damage caused by patient misuse (e.g., biting hard objects, sports-related trauma) is not covered under warranty and will be billed separately.
- Confidentiality: All patient records, radiographic images, and treatment plans are maintained in strict confidence in accordance with the health data protection regulations of the Democratic Republic of Congo.
- Dispute Resolution: Any disputes arising from this Quotation Estimate shall be resolved amicably. In the event of failure to reach a mutual agreement, the matter shall be submitted to the competent medical arbitration body in Kinshasa, DR Congo.
By signing below, the patient (or legal guardian) acknowledges that they have received, read, and understood this Quotation Estimate for Orthodontist services in DR Congo Kinshasa. The patient consents to the proposed treatment plan and agrees to the payment terms outlined herein.
Patient / Legal Guardian SignatureName: _________________________
Date: _________________________
Orthodontist — Kinshasa Advanced Orthodontic Center
Date: 15 June 2025
Stamp:
© 2025 Kinshasa Advanced Orthodontic Center — DR Congo Kinshasa. This Quotation Estimate document is the property of the issuing Orthodontist practice and shall not be reproduced without written consent.
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