Quotation Estimate Orthodontist in Israel Tel Aviv –Free Word Template Download with AI
Prepared by a Licensed Orthodontist in Israel Tel Aviv
Clinic: Tel Aviv Advanced Orthodontics Center
Address: 42 Dizengoff Street, Tel Aviv-Yafo, Israel 6310000
Phone: +972-3-517-8842
Email: [email protected]
License No.: IL-ORT-2019-00342
Patient Name: Daniel Levi
ID Number: 023-456-789
Address: 18 Allenby Road, Tel Aviv, Israel
Phone: 052-334-7712
Referring Physician: Dr. Miriam Katz, General Dentist
1. Purpose of This Quotation EstimateThis Quotation Estimate has been prepared by Dr. Yael Ben-Shimon, a board-certified Orthodontist practicing in Israel Tel Aviv, following a comprehensive clinical examination, panoramic radiograph (OPG), cephalometric analysis, intraoral digital impressions, and a full periodontal assessment conducted on 10 June 2025. The purpose of this document is to provide the patient with a transparent, itemized financial projection for the recommended orthodontic treatment. All prices listed in this Quotation Estimate are expressed in New Israeli Shekels (NIS / ILS) and are inclusive of VAT at the current rate of 18%, as mandated by the Israel Tax Authority.
2. Recommended Treatment PlanBased on the clinical findings, the Orthodontist recommends a full-course orthodontic intervention using a combination of fixed ceramic brackets on the upper arch and a clear aligner system (Invisalign) on the lower arch. The estimated total treatment duration is 24 to 30 months. The following table details each component of the treatment as outlined in this Quotation Estimate:
| # | Service / Item Description | Quantity | Unit Price (NIS) | Subtotal (NIS) |
|---|---|---|---|---|
| 1 | Initial consultation, clinical examination, and diagnostic records (OPG, cephalo, photos, digital scans) | 1 | 1,200.00 | 1,200.00 |
| 2 | Extraction of four premolars (upper and lower) under local anesthesia | 4 | 850.00 | 3,400.00 |
| 3 | Placement of fixed ceramic (tooth-colored) brackets – upper arch (14 brackets + bonding) | 1 | 7,500.00 | 7,500.00 |
| 4 | Invisalign clear aligner system – lower arch (approximately 28 aligner sets) | 1 | 12,800.00 | 12,800.00 |
| 5 | Monthly adjustment and monitoring visits (Orthodontist appointment, 24 months) | 24 | 450.00 | 10,800.00 |
| 6 | Interproximal reduction (IPR) and minor tooth reshaping as needed | 1 | 1,500.00 | 1,500.00 |
| 7 | Removable retainers (upper and lower) – Essix type, including one replacement set | 2 | 950.00 | 1,900.00 |
| 8 | Post-treatment panoramic radiograph and final clinical evaluation | 1 | 600.00 | 600.00 |
| 9 | Emergency / unplanned visits (estimated allowance, up to 3 visits) | 3 | 300.00 | 900.00 |
| 10 | Orthodontic elastics, O-rings, and auxiliary appliances (consumables over full course) | 1 | 1,200.00 | 1,200.00 |
| TOTAL ESTIMATED COST (Inclusive of 18% VAT) | 43,800.00 NIS | |||
The Orthodontist at this clinic in Israel Tel Aviv offers the following payment structures for the treatment described in this Quotation Estimate:
| Option | Structure | Monthly Payment (NIS) | Duration |
|---|---|---|---|
| A | Full payment upfront (5% discount applied) | — | One-time: 41,610.00 NIS |
| B | Installment plan – 24 equal monthly payments | 1,825.00 | 24 months |
| C | Installment plan – 36 equal monthly payments | 1,350.00 | 36 months |
| D | Health insurance co-payment (Maccabi / Clalit / Meuhedet / HMOFED) | Varies | Per policy terms |
Validity: This Quotation Estimate is valid for 30 calendar days from the date of issue. After this period, prices may be subject to revision due to changes in material costs, supplier pricing, or regulatory adjustments in Israel Tel Aviv.
Scope: The figures presented are estimates based on the current clinical condition. Should the Orthodontist identify additional needs during the course of treatment (e.g., extra extractions, restorative work, or extended retention), a supplementary Quotation Estimate will be issued and must be approved in writing by the patient before any additional procedures are performed.
Insurance: The patient is advised to verify coverage with their respective health fund (Kupat Cholim) prior to commencing treatment. This Quotation Estimate does not constitute a guarantee of insurance reimbursement.
Compliance: All orthodontic procedures are performed in accordance with the regulations of the Israeli Ministry of Health and the standards set by the Israeli Dental Association (IDA). The treating Orthodontist holds a valid license to practice in Israel Tel Aviv and is a member in good standing of the IDA Orthodontic Division.
5. Terms and Conditions1. This Quotation Estimate is a non-binding financial projection and does not constitute a binding contract until a separate Treatment Consent Form is signed by the patient.
2. The patient agrees to attend all scheduled appointments with the Orthodontist. Missed appointments may result in additional fees of 200 NIS per occurrence.
3. In the event of early discontinuation of treatment at the patient's request, a cancellation fee equivalent to 15% of the remaining treatment balance will be applied.
4. All personal health data is handled in strict compliance with the Israeli Privacy Protection Law, 5741-1981, and the EU General Data Protection Regulation (GDPR) where applicable.
5. Disputes arising from this Quotation Estimate or the subsequent treatment shall be governed by the laws of the State of Israel and subject to the exclusive jurisdiction of the courts in Tel Aviv, Israel.
6. The Orthodontist reserves the right to modify the treatment plan if clinical circumstances change, provided the patient is informed in writing and given the opportunity to review a revised Quotation Estimate.
Prepared by (Orthodontist):
Dr. Yael Ben-Shimon, D.D.S., M.Sc. Orthodontics
License No.: IL-ORT-2019-00342
Signature & Date
Received and Acknowledged by (Patient):
Mr. Daniel Levi
ID: 023-456-789
Signature & Date
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