Quotation Estimate Orthodontist in Indonesia Jakarta –Free Word Template Download with AI
Orthodontist Professional Services — Indonesia Jakarta
Document Reference: QTE-ORTHO-JKT-2025-0472
1. Purpose of This Quotation EstimateThis Quotation Estimate is issued by our Orthodontist practice located in Indonesia Jakarta to provide a comprehensive, transparent, and itemized breakdown of all anticipated costs associated with orthodontic treatment. This document serves as a formal financial projection and is intended to assist the client in making an informed decision regarding the scope, duration, and investment required for complete orthodontic care. All pricing in this Quotation Estimate reflects current market rates for Orthodontist services in the Indonesia Jakarta metropolitan area as of the date of issuance.
2. Patient & Clinical Summary| Item | Details |
|---|---|
| Patient Name | [Full Name] |
| Age / Gender | [Age] / [Gender] |
| Diagnosis | Class II Malocclusion with Crowding (Upper & Lower Arch) |
| Recommended Treatment | Comprehensive Fixed Orthodontic Braces (Ceramic) with Retention Phase |
| Estimated Duration | 24 to 30 months (including retention) |
| Treating Orthodontist | Dr. Anindya Wijaya, Sp.KG — Indonesia Jakarta |
| No. | Service / Procedure | Frequency | Unit Cost (IDR) | Total (IDR) |
|---|---|---|---|---|
| 1 | Initial Consultation & Diagnostic Records (X-rays, OPG, Panoramic, Intraoral Photos, Digital Scan) | One-time | 2,500,000 | 2,500,000 |
| 2 | Pre-Orthodontic Treatment (Extractions, Scaling, Fillings as indicated) | One-time | 4,800,000 | 4,800,000 |
| 3 | Placement of Ceramic Fixed Braces (Upper & Lower Arch, including bonding, brackets, archwires, ligatures) | One-time | 35,000,000 | 35,000,000 |
| 4 | Monthly Orthodontist Adjustment & Monitoring Visits (archwire changes, elastic adjustments, progress evaluation) | 24 months | 1,200,000 | 28,800,000 |
| 5 | Debonding & Finishing (removal of brackets, polishing, occlusal adjustment) | One-time | 3,500,000 | 3,500,000 |
| 6 | Retention Phase (Fixed Retainers Upper & Lower + Removable Retainer Fabrication) | One-time | 5,500,000 | 5,500,000 |
| 7 | Retention Follow-Up Visits (every 3 months for 12 months) | 4 visits | 500,000 | 2,000,000 |
| 8 | Emergency / Unscheduled Adjustments (bracket re-bonding, wire trimming, elastic replacement) | Up to 3 times | 400,000 | 1,200,000 |
| GRAND TOTAL (Quotation Estimate) | IDR 83,300,000 | |||
| Installment | Due Date | Amount (IDR) | Remarks |
|---|---|---|---|
| 1st (Down Payment) | Upon signing this Quotation Estimate | 25,000,000 | Covers consultation, diagnostics, pre-treatment, and brace placement |
| 2nd | Month 6 of treatment | 20,000,000 | Covers months 1–6 adjustment visits |
| 3rd | Month 12 of treatment | 20,000,000 | Covers months 7–12 adjustment visits |
| 4th (Final) | Month 18 of treatment | 18,300,000 | Covers remaining visits, debonding, retention, and follow-ups |
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiry date, the Orthodontist practice in Indonesia Jakarta reserves the right to revise pricing based on updated material costs and service rates.
- Scope of Work: All procedures listed herein are subject to clinical re-evaluation by the treating Orthodontist. Should additional interventions become necessary during treatment (e.g., extra extractions, auxiliary appliances, or extended treatment duration), a supplementary Quotation Estimate will be issued and must be approved in writing by the client before any additional work commences.
- Cancellation Policy: In the event the client cancels treatment after brace placement, a non-refundable fee of IDR 15,000,000 shall apply to cover materials already bonded and clinical time invested by the Orthodontist team in Indonesia Jakarta.
- Payment Method: Payments may be made via bank transfer (BCA, Mandiri, BNI), credit/debit card, or cash at the clinic located in Jakarta, Indonesia. All transactions are subject to applicable Indonesian tax regulations (PPN 11% if applicable to the entity).
- Warranty: The Orthodontist practice guarantees the integrity of all bonded appliances for a period of twelve (12) months from debonding. Normal wear and tear or damage caused by patient non-compliance (e.g., biting hard objects, failure to wear retainers) is excluded from this warranty.
- Confidentiality: All patient records, diagnostic images, and financial details contained in this Quotation Estimate are treated as strictly confidential in accordance with Indonesian Health Law (UU No. 17 Tahun 2023) and the clinic's data protection policy.
- Governing Law: This Quotation Estimate and any disputes arising therefrom shall be governed by the laws of the Republic of Indonesia. Jurisdiction shall lie with the competent courts in Jakarta, Indonesia.
By signing below, the client acknowledges that they have read, understood, and accepted all terms, conditions, and cost projections outlined in this Quotation Estimate for Orthodontist services provided in Indonesia Jakarta.
For the Orthodontist PracticeDr. Anindya Wijaya, Sp.KG
Jakarta, Indonesia
Date: _______________ Client / Authorized Representative
Name: _______________
Signature: _______________
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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