Quotation Estimate Orthodontist in Israel Jerusalem –Free Word Template Download with AI

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Client Information

Scope of Orthodontic Treatment

Following a comprehensive clinical examination, radiographic assessment (panoramic X-ray and cephalometric analysis), and digital intraoral scanning conducted on 10 June 2025 at our clinic in Israel Jerusalem, the undersigned Orthodontist has determined that the patient requires full-arch fixed orthodontic treatment. This Quotation Estimate outlines the complete treatment plan, estimated duration, and associated costs for the orthodontic care to be provided by Dr. Miriam Levi and her team at the Israel Jerusalem practice.

The recommended treatment involves the placement of ceramic (tooth-coloured) fixed brackets on all twenty-eight permanent teeth, with an estimated total treatment duration of twenty-four (24) months, including active treatment and a retention phase. The Orthodontist will conduct bi-weekly adjustment appointments throughout the active phase and monthly check-ups during the retention period.

Itemized Cost Breakdown

All prices are quoted in Israeli New Shekels (ILS) and include 18% Value Added Tax (VAT) as mandated by the Israel Tax Authority. This Quotation Estimate does not include the cost of any additional dental procedures (e.g., extractions, restorations) that may be identified during the course of treatment. Such additional procedures will be subject to a separate written estimate approved by the patient prior to execution.

Payment Schedule

The Orthodontist in Israel Jerusalem offers the following payment structure for this Quotation Estimate:

Alternative payment via Maccabi Health Services reimbursement (up to 40% of the approved orthodontic fee schedule) may be applied. The patient is responsible for the remaining balance. A 1.5% monthly interest will be applied to any overdue installment.

Terms and Conditions

1. This Quotation Estimate is valid for thirty (30) days from the date of issue. After the expiry date, the Orthodontist reserves the right to revise pricing due to changes in material costs, supplier pricing, or regulatory adjustments within Israel.

2. The estimated treatment duration of twenty-four months is a clinical projection. The actual duration may vary depending on the patient's biological response, compliance with oral hygiene instructions, and attendance at all scheduled appointments at the Israel Jerusalem clinic.

3. The patient agrees to attend all bi-weekly adjustment appointments. Missed appointments exceeding three (3) consecutive visits may result in a re-evaluation fee of 500 ILS per visit.

4. In the event of early discontinuation of treatment at the patient's request, a pro-rata charge for unused appointments and materials will apply as determined by the Orthodontist.

5. This Quotation Estimate does not constitute a guarantee of a specific aesthetic or functional outcome. The Orthodontist will exercise the highest standard of clinical care in accordance with the guidelines of the Israeli Society of Orthodontics and the regulations of the Israeli Ministry of Health.

6. All personal health data collected in connection with this treatment will be handled in strict compliance with the Israeli Privacy Protection Law, 5741-1981, and the regulations of the Israel Jerusalem medical data authority.

7. Any disputes arising from this Quotation Estimate shall be subject to the jurisdiction of the competent courts in Jerusalem, Israel.

Acceptance and Authorization

By signing below, the patient acknowledges having received and reviewed this Quotation Estimate in full. The patient confirms that the Orthodontist has explained the proposed treatment plan, alternative options (including clear aligner therapy and no treatment), potential risks, and the total estimated cost. The patient authorizes Dr. Miriam Levi and the Israel Jerusalem orthodontic team to commence treatment as described herein.