Quotation Estimate Orthodontist in France Marseille –Free Word Template Download with AI
12 Boulevard du Longchamp, 13001 Marseille, France
Tel: +33 4 91 23 45 67 | Email: [email protected]
SIRET: 842 567 891 00012 | RPPS: 10101234567
Registered Orthodontist — Ordre des Médecins, France Quotation EstimateQuotation Details
Quotation No.: QE-2025-04871
Date Issued: 14 June 2025
Valid Until: 14 September 2025
Currency: EUR (€)
Patient / Client Information
Name: [Patient Full Name]
Date of Birth: [DD/MM/YYYY]
Address: [Patient Address, Marseille, France]
Insurance: Sécurité Sociale + Mutuelle
Referral: Dr. Sophie Bernard (General Dentist)
Dear Patient,
Thank you for consulting our Orthodontist practice here in France Marseille. Following your comprehensive initial examination and diagnostic imaging session conducted on 10 June 2025, we are pleased to present this detailed Quotation Estimate outlining the full scope of orthodontic treatment recommended for your case. This Quotation Estimate has been prepared in accordance with the French national health regulations and the tariff guidelines established by the Conseil National de l'Ordre des Médecins. All prices listed below are inclusive of applicable French Value Added Tax (TVA) at the reduced rate of 10% for medical services.
Itemized Treatment Plan & Pricing| Ref. | Service / Procedure | Description | Unit Price (€) | Qty | Subtotal (€) | SS Reimbursement |
|---|---|---|---|---|---|---|
| 01 | Initial Orthodontic Consultation & Diagnostic Workup | Full clinical examination, panoramic X-ray (OPG), cephalometric radiograph, intraoral photographs, digital impressions, and treatment planning by the Orthodontist | 220.00 | 1 | 220.00 | 0.00 |
| 02 | Fixed Orthodontic Braces — Upper Arch | Ceramic self-ligating brackets (14 units), archwires, elastic ligatures, and bonding materials. Includes all monthly adjustment visits over the estimated 18-month treatment period. | 2,850.00 | 1 | 2,850.00 | 1,425.00 |
| 03 | Fixed Orthodontic Braces — Lower Arch | Ceramic self-ligating brackets (14 units), archwires, elastic ligatures, and bonding materials. Includes all monthly adjustment visits over the estimated 18-month treatment period. | 2,850.00 | 1 | 2,850.00 | 1,425.00 |
| 04 | Interproximal Reduction (IPR) & Minor Tooth Contouring | Selective enamel reduction on up to 6 teeth to create space for optimal alignment, performed by the Orthodontist during active treatment phases. | 380.00 | 1 | 380.00 | 0.00 |
| 05 | Removable Retainer — Upper & Lower (Vivaneau Type) | Acrylic-based retainers with wire, fabricated after debonding. Includes one complimentary replacement within the first 12 months. | 420.00 | 1 | 420.00 | 0.00 |
| 06 | Debonding & Finishing (Both Arch) | Removal of all brackets, archwires, and bonding cement; polishing and final occlusal adjustment by the Orthodontist. | 350.00 | 1 | 350.00 | 175.00 |
| 07 | Post-Treatment Follow-Up Visits (12 months) | Six scheduled check-up appointments (every 2 months) to monitor retention, adjust retainers if necessary, and ensure long-term stability of results. | 85.00 | 6 | 510.00 | 0.00 |
| 08 | Emergency / Unscheduled Adjustment Visits | Provisional allowance for up to 3 unscheduled visits for bracket re-cementation, wire adjustment, or minor appliance repair during the active treatment phase. | 95.00 | 3 | 285.00 | 0.00 |
| TOTAL ESTIMATED COST (TVA 10% included) | € 7,865.00 | € 3,025.00 | ||||
| PATIENT RESPONSIBLE AMOUNT (after Sécurité Sociale) | € 4,840.00 | — | ||||
This Quotation Estimate is based on the clinical findings from your initial consultation and the diagnostic records obtained at our France Marseille practice. The total estimated treatment duration is approximately 18 to 22 months, subject to individual biological response. The Orthodontist reserves the right to adjust the treatment plan should unforeseen clinical circumstances arise during the course of therapy. Any additional procedures not listed in this Quotation Estimate (such as orthognathic surgery referral, periodontal intervention, or additional radiographic imaging) will be communicated and priced separately with your prior written consent.
The Sécurité Sociale reimbursement figures indicated are estimates based on the current French national tariff (Acte de la nomenclature) and may vary depending on your specific mutuelle (supplementary health insurance) coverage. We strongly recommend that you verify your exact reimbursement percentage with your mutuelle provider before commencing treatment. Our practice in France Marseille is fully registered with the CPAM (Caisse Primaire d'Assurance Maladie) and accepts direct billing for covered orthodontic acts.
Payment Terms & Conditions1. A deposit of 20% of the total estimated cost (€ 1,573.00) is required to confirm your treatment slot and schedule the first active appointment. The remaining balance may be settled in full upon completion of treatment or divided into up to 12 monthly installments of € 403.33 without additional interest, as per our France Marseille practice policy.
2. This Quotation Estimate is valid for a period of 90 days from the date of issue. Should you wish to proceed after the validity period, the Orthodontist will re-evaluate the clinical situation and issue a revised Quotation Estimate if any changes to the treatment plan are warranted.
3. All payments are accepted via bank transfer (virement bancaire), credit/debit card, or in-person at our reception in Marseille. A formal invoice (facture) will be issued for each payment to facilitate your Sécurité Sociale and mutuelle reimbursement claims.
4. In the event that treatment is discontinued by the patient before completion, the deposit and all fees for services already rendered will be non-refundable. The Orthodontist will provide a written summary of work completed for your records.
5. This Quotation Estimate does not constitute a binding medical contract. Final treatment decisions rest with the treating Orthodontist in consultation with the patient. All procedures will be performed in strict compliance with French medical law, the Code de la Santé Publique, and the ethical code of the French Orthodontic Society (SFO).
6. Patient data and medical records are handled in full compliance with the French Data Protection Act and the EU General Data Protection Regulation (GDPR). Your information will not be shared with third parties without explicit written consent.
Orthodontist Signature & StampDr. Laurent Moreau, D.O. Patient Acknowledgment & Signature
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT