Quotation Estimate Orthodontist in Netherlands Amsterdam –Free Word Template Download with AI
Document Reference: QTE-2025-AMST-04782
Amsterdam Orthodontic CentrePrinsengracht 427, 1016 KE Amsterdam, Netherlands
Phone: +31 (0)20 555 0142 | Email: [email protected]
KvK (Chamber of Commerce): 74829315 | IBG Registration: 12345678
Specialist Orthodontist Practice – Licensed under Dutch Healthcare Act (Wgbo) Patient Name: J. van der Berg
Date of Birth: 14 March 1998
Insurance Provider: Zilveren Kruis
Policy Number: ZK-882345671
Referring Dentist: Dr. A. de Vries, Amsterdam Dental Clinic Quotation Date: 12 June 2025
Valid Until: 12 September 2025
Treating Orthodontist: Dr. M. Jansen, MSc Orth.
Consultation Date: 5 June 2025 1. Diagnosis & Treatment Description
Following a comprehensive orthodontic consultation conducted at our Amsterdam practice on 5 June 2025, the treating Orthodontist, Dr. M. Jansen, has assessed the patient's dental and skeletal condition. The diagnosis reveals a Class II malocclusion with moderate crowding in the upper arch (approximately 6 mm) and a mild crossbite in the lower left posterior region. The patient presents with a deep overbite of 4 mm and a midline deviation of 1.5 mm to the right.
The recommended treatment plan involves the use of a full-arch ceramic (tooth-coloured) fixed appliance system on both the upper and lower arches, combined with temporary anchorage devices (TADs) to facilitate posterior retraction without compromising anterior tooth position. The estimated total treatment duration is 24 to 30 months, including an active phase of approximately 18 months and a retention phase of 12 months.
2. Itemised Cost Breakdown| Item / Procedure | Description | Quantity | Unit Price (EUR) | Subtotal (EUR) |
|---|---|---|---|---|
| Initial Consultation & Diagnostics | Includes panoramic X-ray (OPG), cephalometric radiograph, intraoral photographs, digital impressions, and clinical examination by the Orthodontist | 1 | € 185.00 | € 185.00 |
| Ceramic Fixed Appliance – Upper Arch | Tooth-coloured brackets and archwire system, 14 brackets, bonded to upper teeth | 1 | € 1,450.00 | € 1,450.00 |
| Ceramic Fixed Appliance – Lower Arch | Tooth-coloured brackets and archwire system, 14 brackets, bonded to lower teeth | 1 | € 1,350.00 | € 1,350.00 |
| Temporary Anchorage Devices (TADs) | Two mini-screws for posterior retraction mechanics, including placement and removal | 2 | € 280.00 | € 560.00 |
| Monthly Adjustment Visits | Archwire changes, elastic adjustments, and clinical monitoring by the Orthodontist (estimated 18 visits) | 18 | € 95.00 | € 1,710.00 |
| Interproximal Reduction (IPR) | Minor enamel reduction to create space for alignment (estimated 4 mm total) | 1 | € 320.00 | € 320.00 |
| Appliance Removal & Final Records | Debonding, polishing, final radiographs, and digital scan for retainer fabrication | 1 | € 250.00 | € 250.00 |
| Fixed Retainer – Upper & Lower | Bonded retainer wire behind anterior teeth, both arches, with 12-month retention monitoring | 2 | € 195.00 | € 390.00 |
| Removable Night Retainer (ESM) | Thermoplastic Essix retainer, upper and lower, for nighttime wear during retention phase | 2 | € 145.00 | € 290.00 |
| Emergency / Unscheduled Visits | Provisional allowance for up to 3 unscheduled visits (broken bracket, wire irritation, etc.) | 3 | € 65.00 | € 195.00 |
| TOTAL ESTIMATED COST (excl. VAT) | € 6,700.00 | |||
| VAT (21% – Dutch standard rate) | € 1,407.00 | |||
| GRAND TOTAL (incl. VAT) | € 8,107.00 | |||
In the Netherlands, orthodontic treatment for patients under the age of 18 is covered under the basic health insurance (zorgverzekering) as mandated by the Dutch Healthcare Act. For adult patients (18 and older), orthodontic treatment is generally considered a voluntary (vrijwillige) or supplementary insurance benefit. The patient, being 27 years of age, is advised to verify coverage under the supplementary orthodontic module of their Zilveren Kruis policy.
Our practice in Amsterdam, Netherlands, is registered with the Dutch Dental Association (Nederlandse Tandartsen Vereniging) and the Orthodontists Association (Nederlandse Orthodontische Vereniging, NOV). We provide a detailed treatment plan and cost estimate that can be submitted to the insurance provider for pre-approval. The patient is responsible for any co-payment (eigen risico) or non-covered portions as determined by the insurer.
4. Payment TermsThe total Quotation Estimate amount of € 8,107.00 (including VAT) may be settled in full upon commencement of treatment or through a monthly instalment plan of € 338.00 over 24 months, with no additional interest. A deposit of € 500.00 is required to secure the treatment start date. Payment is due within 14 calendar days of invoice issuance. Late payments are subject to a statutory interest rate of 8% per annum in accordance with Dutch civil law (Burgerlijk Wetboek, Book 6).
Validity Notice: This Quotation Estimate is valid for a period of 90 days from the date of issue (12 June 2025). Prices are subject to change due to material cost fluctuations, regulatory adjustments in the Netherlands, or changes in the scope of treatment as determined by the treating Orthodontist. This document is a non-binding estimate and does not constitute a final invoice. 5. Terms & Conditions- This Quotation Estimate is prepared by the Amsterdam Orthodontic Centre and is specific to the named patient. It may not be transferred to another individual.
- The treating Orthodontist reserves the right to modify the treatment plan if clinical findings change during the course of therapy. Any additional procedures will be communicated and agreed upon in writing before execution.
- The patient is expected to attend all scheduled appointments at our Amsterdam, Netherlands practice. Missed appointments without 48-hour prior notice may incur a fee of € 75.00.
- The patient must maintain adequate oral hygiene throughout treatment. Failure to do so may result in decalcification, gingival inflammation, or appliance damage, which may necessitate additional visits and costs not included in this estimate.
- Retention is a critical component of orthodontic treatment. The patient commits to wearing the prescribed retainers as directed by the Orthodontist for a minimum of 12 months post-active treatment.
- All personal data is processed in accordance with the General Data Protection Regulation (GDPR) and the Dutch Implementation Act (UAVG). Data is stored securely and will not be shared with third parties without explicit consent, except as required by Dutch law.
- In the event of a dispute, the patient may contact the Dutch Dental Complaints Board (Klachtcommissie Tandartsen) or the Orthodontic Complaints Committee. The practice is also a member of the Dutch Mediation Board for Healthcare (Mediation Board for Healthcare, MGH).
- This Quotation Estimate does not guarantee a specific aesthetic or functional outcome, as individual biological responses to orthodontic mechanics vary.
For the Amsterdam Orthodontic Centre
Dr. M. Jansen, MSc Orth.
Specialist Orthodontist
Date: _______________
Signature: _______________
Patient / Legal Guardian
J. van der Berg
I acknowledge receipt of this Quotation Estimate.
Date: _______________
Signature: _______________
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