Quotation Estimate Orthodontist in Ethiopia Addis Ababa –Free Word Template Download with AI
Orthodontist Services — Ethiopia Addis Ababa
Ref: QTE-ADD-2025-0472Provider Details
Dr. Selamawit Bekele, DDS, MS
Lead Orthodontist
Addis Ababa Smile Orthodontic Center
Bole Road, Near Friendship Hotel
Addis Ababa, Ethiopia
Tel: +251-11-555-0142
Email: [email protected]
Client Details
Mr. Tesfaye Alemu
Patient / Account Holder
House No. 14, Woreda 03
Kazanchis, Addis Ababa
Ethiopia
Tel: +251-91-234-5678
Email: [email protected]
Document Information
Quotation Estimate Date: 15 June 2025
Valid Until: 15 July 2025 (30 days)
Currency: Ethiopian Birr (ETB)
Prepared By: Dr. Selamawit Bekele
Diagnosis Summary
Condition: Class II Malocclusion with Crowding
Recommended Treatment: Comprehensive Fixed Orthodontic Appliance
Estimated Duration: 24–30 months
Referral Source: Self-Referral
| No. | Service / Procedure Description | Frequency | Unit Price (ETB) | Total (ETB) | Notes |
|---|---|---|---|---|---|
| 1 | Initial Consultation & Comprehensive Diagnostic Records (Panoramic X-ray, Cephalometric X-ray, Intraoral Photographs, Digital Impressions) | One-time | 4,500.00 | 4,500.00 | Includes treatment plan |
| 2 | Pre-Orthodontic Dental Hygiene & Scaling (Full Mouth) | One-time | 3,200.00 | 3,200.00 | Required before appliance placement |
| 3 | Extraction of Premolars (4 teeth) with Local Anesthesia | One-time | 2,800.00 | 11,200.00 | Per tooth rate applied |
| 4 | Placement of Fixed Metal Brackets & Archwires (Full Mouth — 28 brackets) | One-time | 38,000.00 | 38,000.00 | Includes bonding agent |
| 5 | Monthly Orthodontist Adjustment & Wire Changes (24 sessions) | Monthly × 24 | 2,500.00 | 60,000.00 | Includes elastic replacements |
| 6 | Interproximal Reduction (IPR) — Selective Enamel Reduction | As needed | 1,500.00 | 4,500.00 | Estimated 3 sessions |
| 7 | Removable Retainer Fabrication (Upper & Lower — 2 sets) | One-time | 5,500.00 | 11,000.00 | Acrylic Hawley type |
| 8 | Post-Treatment Follow-Up & Retainer Adjustments (6 months) | Every 6 weeks | 1,200.00 | 7,200.00 | 6 visits included |
| 9 | Emergency Orthodontist Visit (Broken bracket, wire irritation) — Up to 3 visits | As needed | 1,800.00 | 5,400.00 | First 3 visits covered |
| 10 | Final Panoramic X-ray & Post-Treatment Records | One-time | 2,000.00 | 2,000.00 | For treatment documentation |
| GRAND TOTAL (Quotation Estimate) | ETB 147,000.00 | ||||
- Deposit: A non-refundable deposit of 30% (ETB 44,100.00) is required to schedule the initial treatment appointment and reserve the Orthodontist's calendar.
- Installment Plan: The remaining balance may be paid in equal monthly installments over the duration of active treatment (24 months). No interest is charged on the installment plan.
- Payment Methods: Cash, bank transfer (CBE, Awash Bank, Dashen Bank), or mobile money (Telebirr, M-Pesa Ethiopia) are accepted at our clinic in Addis Ababa.
- Validity: This Quotation Estimate is valid for 30 calendar days from the date of issue. After expiry, a revised estimate reflecting any changes in material costs will be provided.
- Cancellation Policy: Should the patient decide to discontinue treatment after the initial consultation, the deposit is non-refundable. If treatment is discontinued after bracket placement, 50% of the total Quotation Estimate amount is non-refundable.
- Warranty: The Orthodontist guarantees the integrity of all bonded brackets and wires for 12 months from placement, excluding damage caused by patient negligence (e.g., biting hard objects, sports-related trauma).
- Confidentiality: All patient records, radiographs, and treatment plans are maintained in strict accordance with Ethiopian medical privacy regulations. No information will be shared without written consent.
- Location: All services described in this Quotation Estimate will be performed at our clinic located on Bole Road, Addis Ababa, Ethiopia. The clinic operates Monday through Saturday, 8:00 AM to 6:00 PM.
By signing below, the patient acknowledges receipt of this Quotation Estimate for Orthodontist services in Ethiopia Addis Ababa and agrees to the terms and conditions outlined above. The patient confirms that the proposed treatment plan has been explained in understandable terms and that all questions have been satisfactorily answered by the treating Orthodontist.
Patient SignatureName: Tesfaye Alemu
Date: _______________ Orthodontist / Provider Signature
Name: Dr. Selamawit Bekele, DDS, MS
License No: ETH-ORTHO-2019-0087
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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