Quotation Estimate Orthodontist in Italy Rome –Free Word Template Download with AI

Quotation Estimate

Quotation No. QE-2025-0347 Date of Issue: 12 June 2025 | Valid Until: 12 September 2025

Prepared For (Patient)

Name: Sig.ra Elena Marchetti

Address: Via Appia Nuova, 87, 00179 Roma (RM), Italy

Phone: +39 333 456 7890

Email: [email protected]

Codice Fiscale: MRCLEA85A41H501Y

Prepared By (Orthodontist)

Dr. Marco Bellini, DDS, MSc

Specialist in Orthodontics and Dentofacial Orthopedics

Clinic: Studio Ortodontico Dr. Bellini

Location: Rome, Lazio, Italy

Referral Doctor: Dr. Lucia Ferrante (General Dentist)

This Quotation Estimate has been prepared by Dr. Marco Bellini, a registered Specialist Orthodontist practising in Rome, Italy, following a comprehensive clinical examination, panoramic radiograph (OPG), intraoral digital impressions, and cephalometric analysis conducted on 5 June 2025 at the clinic located in the historic centre of Rome. The purpose of this document is to provide the patient with a detailed, transparent, and itemised financial estimate for the proposed orthodontic treatment plan. All prices are expressed in Euros (EUR) and are inclusive of the applicable Italian Value Added Tax (IVA) at the current rate of 22%, unless otherwise stated. This Quotation Estimate does not constitute a binding contract; it serves as a good-faith financial projection based on the clinical findings at the time of examination.

Based on the diagnostic evaluation performed in Rome, the following orthodontic treatment is recommended to correct a Class II malocclusion with upper anterior crowding, a deep overbite of 4 mm, and a mild midline deviation. The treatment will be carried out at the orthodontic clinic in central Rome over an estimated duration of 24 to 30 months, with regular follow-up appointments scheduled every six to eight weeks.

#	Description of Service / Item	Unit	Unit Price (EUR)	Total (EUR)
1	Initial diagnostic workup: panoramic radiograph (OPG), lateral cephalogram, intraoral digital scan (iTero), clinical photographs, and orthodontic assessment by the Specialist Orthodontist in Rome	1 session	320.00	320.00
2	Removable upper expander (Hyrax type) with monthly adjustment visits (approximately 6 months of wear)	1 appliance	850.00	850.00
3	Fixed orthodontic brackets and wires — full-arch (upper and lower), including bonding, archwire changes, elastic ligature replacements, and monthly adjustment appointments (estimated 24 visits)	2 arches	3,200.00	6,400.00
4	Interproximal reduction (IPR) / enameloplasty for upper anterior crowding (estimated 8 surfaces)	8 surfaces	35.00	280.00
5	Orthodontic elastics (rubber bands) — monthly supply for the duration of active treatment (approximately 24 months)	24 months	18.00	432.00
6	Removable retention appliances (Hawley retainers, upper and lower) with acrylic base and wire	2 retainers	280.00	560.00
7	Post-treatment follow-up and retainer adjustments (estimated 4 visits over 12 months)	4 visits	60.00	240.00
8	Emergency / unscheduled orthodontic appointments (broken bracket, wire irritation) — estimated allowance	2 visits	80.00	160.00
9	Final post-treatment radiograph and digital records for the orthodontic file	1 session	120.00	120.00
10	Administrative and clinical documentation, treatment planning software, and patient management in compliance with Italian healthcare regulations (D.Lgs. 81/2008, GDPR)	1 package	150.00	150.00
Subtotal (excl. IVA)				9,512.00
IVA 22% (Italian VAT)				2,092.64
GRAND TOTAL (incl. IVA 22%)				11,604.64

Deposit: A non-refundable deposit of 20% (EUR 2,320.93) of the Grand Total is due upon acceptance of this Quotation Estimate and prior to the commencement of active orthodontic treatment at the Rome clinic.
Installment Plan: The remaining balance may be paid in equal monthly installments over the duration of active treatment (approximately 24 months), with a monthly payment of approximately EUR 404.19. No additional interest or administrative fees are charged for the installment plan.
Accepted Payment Methods: Bank transfer (bonifico bancario) to the clinic's Italian IBAN, credit/debit card (Visa, Mastercard, American Express), or cash up to EUR 4,999.99 in compliance with Italian anti-money-laundering regulations (D.Lgs. 231/2007).
Invoicing: A formal Italian invoice (fattura elettronica) will be issued for each payment in accordance with the requirements of the Agenzia delle Entrate. The patient may request a "fattura con detrazione" to claim the 19% tax deduction on out-of-pocket healthcare expenses as provided by the Italian tax code (TUIR, Art. 15).
Price Validity: This Quotation Estimate is valid for a period of 90 days from the date of issue. Should the patient choose to commence treatment after the validity period, the Orthodontist in Rome reserves the right to revise the pricing to reflect any changes in material costs, regulatory fees, or professional fee schedules.

All orthodontic procedures described in this Quotation Estimate will be performed by Dr. Marco Bellini, a Specialist Orthodontist registered with the Ordine degli Odontoiatri della Provincia di Roma, in full compliance with the professional standards set by the Italian Ministry of Health (Ministero della Salute).
The treatment plan may be subject to modification during the course of therapy if the clinical progress in Rome necessitates additional or alternative interventions. Any such changes will be communicated to the patient in writing, with a revised Quotation Estimate issued prior to the additional procedure.
The patient is required to attend all scheduled orthodontic appointments at the clinic in Rome. Missed appointments without at least 48 hours' prior notice will be subject to a cancellation fee of EUR 50.00 per occurrence.
Oral hygiene instructions specific to orthodontic treatment will be provided at the first active-treatment visit. The patient is responsible for maintaining adequate oral hygiene to prevent decalcification, gingivitis, or caries during the treatment period.
This Quotation Estimate is prepared in accordance with the Italian Consumer Code (Codice del Consumo, D.Lgs. 206/2005) and the professional deontological code of the Italian Orthodontic Association (SIO — Società Italiana di Ortodonzia).
In the event of a dispute regarding the scope or cost of the orthodontic treatment, the parties agree to seek resolution through the competent medical-medico-legal authority in the judicial district of Rome, Lazio, Italy.

By signing below, the patient acknowledges having received and reviewed this Quotation Estimate for orthodontic treatment in Rome, Italy, and confirms understanding of the proposed treatment plan, the estimated costs, the payment terms, and the clinical conditions outlined herein. The patient's signature does not constitute an obligation to commence treatment but serves as a record of informed financial disclosure by the Specialist Orthodontist.

Dr. Marco Bellini, DDS, MSc
Specialist Orthodontist
Studio Ortodontico — Rome, Italy
Signature & Date: _________________________ Sig.ra Elena Marchetti
Patient
Signature & Date: _________________________ ⬇️ Download as DOCX Edit online as DOCX

Create your own Word template with our GoGPT AI prompt:

GoGPT