Quotation Estimate Orthodontist in France Lyon –Free Word Template Download with AI
12 Rue de la République, 69002 Lyon, France
Tel: +33 4 72 00 00 00 | Email: [email protected]
SIRET: 842 567 891 00012 | RPPS: 10100123456
Quotation Details
Quotation Reference: QE-2025-0748
Date of Issue: 14 June 2025
Valid Until: 14 September 2025 (90 days)
Prepared By: Dr. Laurent Moreau, D.O. (Orthodontist)
Patient Information
Name: Mme. Sophie Delacroix
Date of Birth: 03 March 1998
Address: 45 Avenue Jean Jaurès, 69007 Lyon, France
National Health No. (NIR): 2 98 03 69 012 345 678
Complementary Insurance (Mutuelle): MGEN
Important Note: This Quotation Estimate has been prepared in accordance with the French national orthodontic fee schedule (Convention Nationale Orthodontique) and the specific regulations governing orthodontic care in Lyon, France. All prices are expressed in Euros (EUR) and are subject to the applicable French healthcare reimbursement framework managed by the Assurance Maladie (Sécurité Sociale) and the patient's complementary health insurance (mutuelle).Description of Orthodontic Treatment Plan
Following a comprehensive clinical examination, radiographic analysis (panoramic X-ray, cephalometric tracing), and digital intraoral scanning performed at our orthodontic practice in Lyon, France, the following treatment plan has been established for the patient. This Quotation Estimate outlines all anticipated orthodontic procedures, associated costs, and the expected reimbursement structure under the French healthcare system.
Itemized Quotation Estimate
| Ref. | Description of Orthodontic Service | Frequency / Duration | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|
| 01 | Initial orthodontic consultation, clinical examination, and diagnostic assessment | One-time | 80.00 | 80.00 |
| 02 | Diagnostic imaging: panoramic radiograph (OPG) and lateral cephalometric X-ray | One-time | 120.00 | 120.00 |
| 03 | Digital intraoral scan and 3D treatment planning (orthodontic software analysis) | One-time | 150.00 | 150.00 |
| 04 | Placement of fixed orthodontic appliance (metal brackets, upper and lower arches) | One-time | 1,850.00 | 1,850.00 |
| 05 | Monthly orthodontic adjustment visits (bracket adjustment, wire changes, elastic replacement) | 18 months | 95.00 | 1,710.00 |
| 06 | Interproximal reduction (IPR) — selective enamel reduction for space creation | As required | 200.00 | 200.00 |
| 07 | Removal of fixed orthodontic appliance and bonding of fixed retainers (upper and lower) | One-time | 350.00 | 350.00 |
| 08 | Post-treatment orthodontic follow-up visits (retention monitoring) | 6 months | 60.00 | 360.00 |
| 09 | Emergency orthodontic appointments (broken bracket, wire irritation — estimated) | Up to 3 visits | 75.00 | 225.00 |
| 10 | Final panoramic radiograph and post-treatment documentation | One-time | 90.00 | 90.00 |
| TOTAL QUOTATION ESTIMATE (before reimbursement) | 5,185.00 | |||
Estimated Reimbursement Structure (France Lyon)
| Reimbursement Source | Estimated Coverage | Amount (EUR) |
|---|---|---|
| Assurance Maladie (Sécurité Sociale) — Orthodontic base rate (forfeit) | Standard orthodontic reimbursement | 1,500.00 |
| Complementary Insurance (MGEN Mutuelle) — Orthodontic supplement | Approximately 60% of remaining eligible costs | 1,800.00 |
| Patient Out-of-Pocket (Reste à Charge) | Remaining balance | 1,885.00 |
Terms and Conditions of This Quotation Estimate
- 1. This Quotation Estimate is valid for a period of 90 days from the date of issue. After this period, prices may be revised in accordance with the current French orthodontic fee schedule and any updates to the Lyon regional healthcare regulations.
- 2. The total treatment duration is estimated at 18 to 24 months. The final number of orthodontic adjustment visits may vary depending on the patient's biological response to treatment. Additional visits beyond the 18 included in this estimate will be billed at the standard rate of 95.00 EUR per visit.
- 3. All orthodontic procedures described in this Quotation Estimate will be performed at our practice located at 12 Rue de la République, 69002 Lyon, France, by Dr. Laurent Moreau or a qualified orthodontic assistant under direct supervision.
- 4. The patient is required to present their French National Health Insurance card (Carte Vitale) and complementary insurance (mutuelle) card at each orthodontic appointment to ensure proper direct reimbursement (tiers payant) processing.
- 5. In the event of treatment interruption exceeding 60 consecutive days without medical justification, the patient will be notified in writing. A re-evaluation fee of 120.00 EUR will apply upon resumption of orthodontic care.
- 6. This Quotation Estimate does not constitute a binding contract. Treatment will commence only after the patient has signed the informed consent form and the orthodontic treatment agreement provided by our practice in Lyon.
- 7. Any additional orthodontic procedures not foreseen at the time of this estimate (e.g., extraction of teeth, placement of orthodontic mini-screws, or auxiliary elastics) will be communicated to the patient in writing prior to execution, with a supplementary Quotation Estimate issued as needed.
- 8. The patient retains the right to request a second opinion from another orthodontist in Lyon or elsewhere in France. Our practice will provide all diagnostic records and imaging upon written request.
- 9. All personal data processed in connection with this Quotation Estimate and the subsequent orthodontic treatment are handled in strict compliance with the French Data Protection Act and the European General Data Protection Regulation (GDPR).
- 10. In the event of any dispute regarding the services described in this Quotation Estimate, the competent jurisdiction shall be the Tribunal Judiciaire de Lyon, France.
Acceptance and Signatures
By signing below, the patient acknowledges having received and reviewed this Quotation Estimate for orthodontic treatment at the practice of Dr. Laurent Moreau in Lyon, France. The patient confirms that all information has been explained in clear terms and that they have had the opportunity to ask questions regarding the proposed orthodontic treatment plan, associated costs, and reimbursement options under the French healthcare system.
Patient: Mme. Sophie Delacroix
Signature & DateOrthodontist: Dr. Laurent Moreau, D.O.
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