Quotation Estimate Orthodontist in Japan Tokyo –Free Word Template Download with AI
Licensed Orthodontist Practice • 4-2-18 Shinjuku, Shinjuku-ku, Tokyo 160-0022, Japan
Tel: +81-3-5555-0198 • Email: [email protected] • License No. TK-ORT-2019-0447
Quotation EstimateQuotation Details
Quotation No.: QE-2025-0712-0034
Date Issued: July 12, 2025
Valid Until: August 12, 2025
Prepared By: Dr. Kenji Tanaka, DDS, MS (Orthodontist)
Patient / Client Information
Name: [Patient Full Name]
Address: [Residential Address, Tokyo, Japan]
Contact: [Phone Number]
Insurance / Payer: [Insurance Provider Name]
Dear Patient,
Thank you for visiting our Orthodontist clinic in Japan Tokyo for a comprehensive consultation regarding your orthodontic treatment needs. Following your initial examination on July 10, 2025, our team has prepared this detailed Quotation Estimate outlining the recommended treatment plan, associated costs, and expected timeline. This document serves as a formal Quotation Estimate for all orthodontic services to be performed at our Japan Tokyo facility.
Recommended Treatment Plan & Itemized Costs| Item No. | Service / Procedure Description | Frequency | Unit Price (JPY) | Estimated Total (JPY) |
|---|---|---|---|---|
| 01 | Initial Comprehensive Orthodontic Examination (includes panoramic X-ray, cephalometric radiograph, intraoral photography, and digital impression scanning) | One-time | ¥18,000 | ¥18,000 |
| 02 | Diagnostic Treatment Planning & Digital Simulation (3D treatment preview provided to patient) | One-time | ¥12,000 | ¥12,000 |
| 03 | Placement of Fixed Metal Braces (upper and lower arches, including bonding of brackets, archwires, and elastic ligatures) | One-time | ¥280,000 | ¥280,000 |
| 04 | Monthly Orthodontic Adjustment Visits (wire changes, elastic adjustments, progress monitoring by the Orthodontist) | 24 months | ¥15,000 | ¥360,000 |
| 05 | Removal of Braces & Bonding of Fixed Retainers (upper and lower arches) | One-time | ¥45,000 | ¥45,000 |
| 06 | Custom Removable Retainer Fabrication (Hawley type, upper and lower) | One-time | ¥30,000 | ¥30,000 |
| 07 | Annual Retention Check-ups (post-treatment monitoring for 2 years) | 2 times | ¥8,000 | ¥16,000 |
| 08 | Emergency / Unscheduled Visits (bracket re-bonding, wire adjustment, or urgent consultation by the Orthodontist) | Up to 3 times | ¥5,000 | ¥15,000 |
| TOTAL ESTIMATED COST (Tax Included, 10% Consumption Tax) | ¥791,000 | |||
- Deposit: A non-refundable deposit of ¥50,000 (approximately 6.3% of the total) is required at the time of accepting this Quotation Estimate to secure your treatment slot with our Orthodontist team in Japan Tokyo.
- Installment Plan: The remaining balance may be paid in 24 equal monthly installments of ¥30,042, deducted via bank transfer or credit card. No additional interest is charged for the standard installment period.
- Insurance Coverage: Please note that in Japan, orthodontic treatment for cosmetic purposes is generally not covered by National Health Insurance (NHI). However, if the treatment is deemed medically necessary (e.g., severe malocclusion affecting mastication or speech), partial coverage may apply. Our front desk will assist you in submitting any applicable insurance claims.
- Validity: This Quotation Estimate is valid for 30 calendar days from the date of issue. Prices are subject to change after the expiration date due to material cost fluctuations or updated fee schedules by the Tokyo Dental Association.
- Treatment Duration: The estimated treatment period is 22 to 26 months. The actual duration may vary depending on individual biological response, compliance with elastic wear instructions, and any unforeseen clinical adjustments made by the Orthodontist.
- Cancellation Policy: Should the patient decide to discontinue treatment after the initial placement of braces, a cancellation fee of ¥80,000 will be applied to cover the cost of de-bonding and materials already utilized.
- Warranty: All brackets, wires, and retainers provided by our clinic carry a 12-month warranty against manufacturing defects. Damage caused by patient misuse (e.g., biting hard objects) is not covered under warranty.
This Quotation Estimate has been prepared specifically for the patient named above and is non-transferable. All orthodontic procedures will be performed or directly supervised by Dr. Kenji Tanaka, a board-certified Orthodontist with over 15 years of clinical experience in the Japan Tokyo metropolitan area. Our clinic adheres to the highest standards of sterilization, patient safety, and ethical practice as mandated by the Japan Dental Association and the Tokyo Metropolitan Government Health Bureau.
Should you have any questions regarding this Quotation Estimate, the proposed treatment plan, or any aspect of your orthodontic care, please do not hesitate to contact our clinic during business hours (Monday to Saturday, 9:00 AM to 6:00 PM; closed Sundays and national holidays). A complimentary follow-up consultation with the Orthodontist is available to address any concerns before you finalize your acceptance of this estimate.
Orthodontist / Clinic RepresentativeDr. Kenji Tanaka, DDS, MS
Shinjuku Smile Orthodontic Clinic, Tokyo, Japan Patient / Authorized Guardian
Signature & Date
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