Quotation Estimate Orthodontist in Iran Tehran –Free Word Template Download with AI
Orthodontist Professional Services — Iran Tehran
Document No: QTE-ORT-2025-04782 Issued By:Dr. Alireza Mohammadi, D.D.S., M.Sc. Orthodontics
Tehran Advanced Orthodontic Center
No. 42, Vali-Asr Street, 12th Floor
Tehran, Iran — Postal Code: 14736-15420
Tel: +98-21-8876-5432 | Email: [email protected] Quotation Estimate Details:
Date of Issue: 15 June 2025
Valid Until: 15 July 2025 (30 days)
Currency: Iranian Rial (IRR) / USD
Payment Terms: See Section 5 1. Client / Patient Information
| Field | Details |
|---|---|
| Patient Full Name | _______________________________ |
| National ID (Kod-e Melli) | _______________________________ |
| Address (Tehran, Iran) | _______________________________ |
| Contact Number | _______________________________ |
| Referring Physician (if applicable) | _______________________________ |
This Quotation Estimate outlines the comprehensive orthodontic treatment plan prepared by our Orthodontist team at the Tehran Advanced Orthodontic Center, located in the heart of Iran Tehran. All pricing reflects current market rates in Tehran and includes the expertise of a board-certified Orthodontist with over 18 years of clinical experience in the Tehran region.
| Item # | Description of Orthodontist Service | Unit | Qty | Unit Price (IRR) | Total (IRR) |
|---|---|---|---|---|---|
| 1 | Initial Consultation & Diagnostic Evaluation (Panoramic X-ray, Cephalometric Analysis, Intraoral Scanning, Clinical Examination by the Orthodontist) | Session | 1 | 2,500,000 | 2,500,000 |
| 2 | Custom Treatment Plan Design & Digital Simulation (3D Smile Preview, Treatment Duration Estimation, Cost Breakdown by the Orthodontist) | Report | 1 | 1,800,000 | 1,800,000 |
| 3 | Fixed Metal Braces — Full Arch (Upper & Lower) — Fabrication, Bonding, and Adjustment by the Orthodontist | Set | 1 | 45,000,000 | 45,000,000 |
| 4 | Monthly Adjustment & Wire Change Sessions (Orthodontist Supervised) — Estimated 18-month treatment | Session | 18 | 1,200,000 | 21,600,000 |
| 5 | Removable Retainer (Hawley Type) — Upper & Lower — Post-Orthodontist Treatment Phase | Set | 1 | 6,500,000 | 6,500,000 |
| 6 | Emergency / Unscheduled Visit (Brace Breakage, Wire Irritation) — Covered by Orthodontist | Visit | 3 | 800,000 | 2,400,000 |
| 7 | Final Debonding, Polishing & Post-Treatment Photography (Performed by the Orthodontist) | Session | 1 | 3,000,000 | 3,000,000 |
| 8 | Annual Retainer Check-Up (First 2 Years Post-Treatment) — Orthodontist Follow-Up | Year | 2 | 1,000,000 | 2,000,000 |
| GRAND TOTAL — Quotation Estimate (Before Tax) | 84,800,000 IRR | ||||
| Approximate USD Equivalent (at 1 USD = 900,000 IRR) | ≈ 94.22 USD | ||||
| Option | Description | Additional Cost (IRR) |
|---|---|---|
| A | Upgrade to Ceramic (Tooth-Colored) Braces — Aesthetic Orthodontist Treatment | +25,000,000 |
| B | Invisible Aligner Therapy (Clear Aligners) — Full Course by the Orthodontist | +60,000,000 |
| C | Interproximal Reduction (IPR) — If Required by the Orthodontist for Space Management | +4,000,000 |
| D | Orthognathic Surgical Consultation Referral (For Severe Jaw Discrepancy) — Coordinated by the Orthodontist | +8,000,000 |
Based on the clinical assessment performed by our Orthodontist in Iran Tehran, the estimated total treatment duration is 18 to 24 months, depending on the complexity of the malocclusion and the patient's compliance with orthodontic instructions. Monthly adjustment appointments will be scheduled at the Tehran Advanced Orthodontic Center, and the patient will be required to attend each session punctually. The Quotation Estimate covers all scheduled visits within this timeframe. Any extension beyond the estimated period will be subject to a revised Quotation Estimate issued by the Orthodontist.
5. Payment Terms & Conditions- Down Payment: 30% of the total Quotation Estimate amount is due at the time of signing the treatment agreement and prior to the initial bonding procedure performed by the Orthodontist.
- Installment Plan: The remaining 70% may be paid in equal monthly installments over the treatment duration. No interest is charged for payments made within the agreed schedule.
- Payment Methods: Bank transfer (Shetab / National Interbank Payment Network), in-person payment at the Tehran clinic, or approved credit/debit cards. All transactions are processed in Iranian Rial (IRR).
- Validity: This Quotation Estimate is valid for 30 calendar days from the date of issue. Due to fluctuating material costs in the Tehran market, prices may be adjusted after the validity period expires.
- Cancellation Policy: If the patient cancels treatment after the initial bonding, 50% of the total Quotation Estimate amount is non-refundable. Cancellation prior to bonding incurs only the consultation fee (Item 1).
- Warranty: The Orthodontist guarantees all bonded appliances against manufacturing defects for the duration of active treatment. Normal wear and tear or damage caused by patient negligence (e.g., biting hard objects) is not covered under this Quotation Estimate.
- Regulatory Compliance: All services are performed in accordance with the regulations set by the Iranian Ministry of Health and Medical Education. The Orthodontist holds a valid license to practice in Tehran, Iran, and the clinic is fully registered with the Tehran Medical Association.
- This Quotation Estimate is a good-faith estimate of costs and is not a binding contract until both parties sign the treatment agreement.
- The Orthodontist reserves the right to modify the treatment plan if clinical findings during active treatment necessitate additional procedures. Any such modifications will be communicated in writing and a supplementary Quotation Estimate will be provided.
- All diagnostic records (X-rays, photographs, digital scans) obtained during the Orthodontist consultation in Iran Tehran remain the property of the clinic but will be shared with the patient upon request.
- The patient is advised to maintain excellent oral hygiene throughout the Orthodontist treatment to prevent decalcification, gingivitis, or other complications that could extend treatment time and alter the Quotation Estimate.
- In the event of force majeure (natural disasters, government-mandated closures in Tehran, etc.), the Orthodontist will reschedule all appointments at no additional cost to the patient.
Lead Orthodontist
Tehran Advanced Orthodontic Center
License No: IR-ORT-2007-44821
Date: _______________ Patient / Legal Guardian
Name: _________________________
Signature: _________________________
Date: _______________ Clinic Administrator
Name: _________________________
Signature: _________________________
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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