Quotation Estimate Orthodontist in India Mumbai –Free Word Template Download with AI
SmileCraft Orthodontic & Dental Clinic
402, Pearl Residency, Linking Road, Bandra West, Mumbai – 400050, Maharashtra, India
Phone: +91-98200-XXXXX | Email: [email protected]
Reg. No.: MH/DC/2019/04521 | Dental Council of India Registered
Orthodontist – Mumbai, India 1. Patient & Clinical Assessment Summary| Field | Details |
|---|---|
| Patient Name | Mr. Arjun Deshmukh (Age: 24, Gender: Male) |
| Referring Orthodontist | Dr. Kavita Nair, BDS, MDS (Orthodontics & Dentofacial Orthopaedics), SmileCraft Orthodontic Clinic, Bandra West, Mumbai |
| Diagnosis | Class II Division 1 malocclusion with moderate crowding in the mandibular arch; overjet of 5 mm; crossbite on the left posterior segment. Cephalometric analysis confirms skeletal Class II pattern. |
| Recommended Treatment | Comprehensive fixed orthodontic treatment using 0.022-inch MBT brackets (upper and lower arches) with auxiliary elastics, followed by a retention phase. Estimated duration: 24–30 months. |
| Pre-Treatment Records | Full-mouth periapical radiographs, panoramic OPG, lateral cephalogram, intraoral photographs (6 views), digital impressions (iTero scanner), and study models – all completed on 05 June 2025. |
| S.No. | Description of Service / Item | Quantity | Unit Price (INR ₹) | Amount (INR ₹) |
|---|---|---|---|---|
| 1 | Comprehensive diagnostic workup (OPG, lateral ceph, periapicals, digital iTero scan, study models, clinical photographs, and orthodontic treatment planning consultation by a specialist Orthodontist in Mumbai) | 1 | ₹ 8,500 | ₹ 8,500 |
| 2 | Extraction of teeth #14, #24, #34, #44 (four premolar extractions under local anaesthesia, including post-operative review and prescription) | 4 | ₹ 2,200 | ₹ 8,800 |
| 3 | Fixed orthodontic appliance – 0.022-inch MBT stainless steel brackets (upper arch, 14 brackets with ligatures and bands) | 1 set | ₹ 32,000 | ₹ 32,000 |
| 4 | Fixed orthodontic appliance – 0.022-inch MBT stainless steel brackets (lower arch, 14 brackets with ligatures and bands) | 1 set | ₹ 32,000 | ₹ 32,000 |
| 5 | Archwires (NiTi, SS, TMA) – full course supply for 24–30 months of active treatment | 1 lot | ₹ 12,000 | ₹ 12,000 |
| 6 | Orthodontic elastics, power chains, and auxiliary components (full treatment duration) | 1 lot | ₹ 4,500 | ₹ 4,500 |
| 7 | Monthly orthodontic adjustment visits (28 visits over 28 months, including wire changes, elastic adjustments, and progress monitoring by the treating Orthodontist) | 28 | ₹ 1,800 | ₹ 50,400 |
| 8 | Debonding of all brackets, bands, and attachments (upper and lower arches) | 1 | ₹ 6,000 | ₹ 6,000 |
| 9 | Post-orthodontic polishing and professional scaling (upper and lower arches) | 1 | ₹ 3,500 | ₹ 3,500 |
| 10 | Fixed lingual retainer (upper and lower arches, 0.016-inch stainless steel wire bonded to palatal/lingual surfaces) + removable Hawley retainer (upper arch) | 1 set | ₹ 14,000 | ₹ 14,000 |
| 11 | Post-treatment follow-up reviews (6 months, 12 months, 18 months, 24 months – 4 visits) | 4 | ₹ 1,200 | ₹ 4,800 |
| 12 | Emergency / unscheduled orthodontic visits (broken bracket, wire irritation, elastic replacement) – estimated allowance | 3 | ₹ 1,500 | ₹ 4,500 |
| Subtotal (INR) | ₹ 181,000 | |||
| GST @ 18% (as applicable under Indian tax regulations for dental/orthodontic services) | ₹ 32,580 | |||
| Grand Total (INR) | ₹ 2,13,580 | |||
| Installment | Due Date / Trigger | Amount (INR ₹) |
|---|---|---|
| Advance (at time of accepting this Quotation Estimate) | Within 7 days of acceptance | ₹ 50,000 |
| Second installment (at appliance bonding / start of active treatment) | Month 1 | ₹ 50,000 |
| Third installment | Month 6 | ₹ 40,000 |
| Fourth installment | Month 12 | ₹ 35,000 |
| Fifth installment | Month 18 | ₹ 25,000 |
| Final installment (at debonding and retention phase) | Month 24–28 | ₹ 13,580 |
- This Quotation Estimate is valid for a period of 30 days from the date of issue. After the expiry date, prices may be revised in accordance with prevailing market rates in Mumbai, India.
- The treating Orthodontist, Dr. Kavita Nair, will personally supervise all aspects of the orthodontic treatment. In her absence, a qualified associate Orthodontist at the clinic will manage routine adjustments.
- Payment may be made via bank transfer, UPI, debit/credit card, or cash. A receipt will be issued for every payment received. No service will commence until the advance payment is confirmed.
- The patient is expected to attend all scheduled monthly appointments. Cancellations must be made at least 48 hours in advance; otherwise, a fee of ₹500 will be charged per missed appointment.
- This estimate does not cover any additional dental procedures (e.g., root canal treatment, periodontal therapy, or restorative work) that may be identified during the course of orthodontic treatment. Such procedures will be quoted separately.
- In the event of appliance damage due to patient negligence (e.g., biting hard objects, sports-related injury), a repair fee of ₹1,000–₹2,500 per incident will apply, in addition to the standard emergency visit charge.
- All clinical records, radiographs, and digital scans will be retained by the clinic for a minimum of 7 years in compliance with the Dental Council of India guidelines applicable in India.
- This Quotation Estimate is non-transferable and is issued exclusively to the named patient. Any change in patient details will require a revised estimate.
- Disputes, if any, arising from this estimate shall be subject to the jurisdiction of the competent courts in Mumbai, Maharashtra, India.
- The clinic operates Monday through Saturday, 10:00 AM to 8:00 PM. Emergency orthodontic appointments can be arranged by phone for patients residing in the Mumbai metropolitan area.
By signing below, the patient (or legal guardian) acknowledges having received and understood this Quotation Estimate for orthodontic treatment at SmileCraft Orthodontic Clinic, Mumbai, India. The patient agrees to the terms, conditions, and payment schedule outlined above.
Patient / Guardian SignatureName: Arjun Deshmukh
Date: _______________
Dr. Kavita Nair, MDS (Ortho.)
Authorised Signatory
Date: _______________
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