Quotation Estimate Orthodontist in Russia Saint Petersburg –Free Word Template Download with AI
Orthodontist Services — Russia Saint Petersburg
Professional Dental & Orthodontic Care
Provider (Orthodontist)
Dr. Elena V. Sokolova, DDS, MSc
Lead Orthodontist, Saint Petersburg Orthodontic Center
Address: 42 Nevsky Prospekt, Saint Petersburg, 191011, Russia
Phone: +7 (812) 555-0142
Email: [email protected]
License No. ЛО-78-01-003847
Client / Patient
Mr. Alexander Dmitrievich Petrov
Address: 15 Liteyny Avenue, Apt. 7
Saint Petersburg, 190000, Russia
Phone: +7 (921) 774-3321
Email: [email protected]
Quotation Estimate No.: QE-2025-04871 Date of Issue: 12 June 2025 Valid Until: 12 July 2025 Currency: Russian Ruble (RUB / &rub;)This Quotation Estimate has been prepared by our qualified Orthodontist in Russia Saint Petersburg to outline the full scope of orthodontic treatment recommended for the patient following a comprehensive clinical examination conducted on 10 June 2025. All pricing reflects current rates at the Saint Petersburg Orthodontic Center and includes all necessary materials, consultations, and follow-up appointments within the treatment period.
| # | Service / Procedure | Description | Qty | Price (RUB) |
|---|---|---|---|---|
| 1 | Initial Orthodontic Consultation & Diagnostic Workup | Full clinical examination by the Orthodontist, panoramic X-ray (OPG), cephalometric radiograph, intraoral 3D digital scan, and treatment plan formulation in Russia Saint Petersburg. | 1 | &rub; 8,500 |
| 2 | Pre-Orthodontic Periodontal Treatment | Professional ultrasonic scaling, air-polishing, and periodontal assessment to ensure optimal oral health prior to appliance placement. | 1 | &rub; 6,200 |
| 3 | Extraction of Premolars (Upper & Lower) | Surgical removal of four premolars (14, 24, 34, 44) under local anaesthesia, performed by the Orthodontist team with post-operative care instructions. | 4 | &rub; 12,000 each |
| 4 | Fixed Metal Braces — Upper Arch | Placement of 14 stainless-steel brackets, archwire, and elastic ligatures on the maxillary arch. Includes bonding agent and adhesive. | 1 | &rub; 45,000 |
| 5 | Fixed Metal Braces — Lower Arch | Placement of 14 stainless-steel brackets, archwire, and elastic ligatures on the mandibular arch. Includes bonding agent and adhesive. | 1 | &rub; 45,000 |
| 6 | Monthly Orthodontic Adjustment Visits | Archwire changes, elastic adjustments, bracket repositioning, and progress monitoring by the Orthodontist. Estimated over 18 months of active treatment in Russia Saint Petersburg. | 18 | &rub; 3,500 each |
| 7 | Interproximal Reduction (IPR) — if required | Minimal enamel reduction between teeth to create space for alignment. Performed as needed during adjustment visits. | Est. 8 | &rub; 800 each |
| 8 | Removable Retainer (Hawley Type) — Upper & Lower | Custom-fabricated acrylic retainers with wire clasps to maintain results after brace removal. Includes one free reline within 12 months. | 2 | &rub; 7,500 each |
| 9 | Post-Orthodontic Follow-Up & Retainer Check | Three follow-up appointments at 3, 6, and 12 months post-treatment to verify retention and make minor adjustments if necessary. | 3 | &rub; 2,000 each |
| 10 | Emergency Orthodontic Visit (if needed) | Urgent appointment for broken bracket, poking wire, or other appliance-related issues during the treatment period. | Est. 2 | &rub; 1,500 each |
| TOTAL ESTIMATED COST (Quotation Estimate) | &rub; 317,100 | |||
- A deposit of 30% of the total Quotation Estimate amount (&rub; 95,130) is due upon acceptance of this document to secure the patient's treatment schedule with the Orthodontist.
- The remaining balance shall be paid in equal monthly instalments over the 18-month active treatment period, or in full at the time of brace placement, at the patient's preference.
- Payment may be made via bank transfer to the Saint Petersburg Orthodontic Center account, cash at the clinic reception, or through approved Russian payment systems (Mir, SBP).
- This Quotation Estimate is valid for 30 calendar days from the date of issue. After the expiry date, the Orthodontist reserves the right to revise pricing due to material cost fluctuations.
- All services are subject to the patient's adherence to the prescribed oral hygiene regimen and attendance at scheduled Orthodontist appointments in Russia Saint Petersburg.
- In the event of early discontinuation of treatment at the patient's request, a cancellation fee of 15% of the remaining balance will apply.
- The Orthodontist provides a 12-month warranty on all bracket bonding and retainer fabrication from the date of placement.
- This Quotation Estimate does not include the cost of any general dental treatments (fillings, crowns, root canals) that may be identified during the diagnostic phase and require separate authorization.
- All personal data is processed in accordance with Federal Law No. 152-FZ "On Personal Data" of the Russian Federation.
By signing below, the patient acknowledges receipt and acceptance of this Quotation Estimate for Orthodontist services in Russia Saint Petersburg and agrees to the terms and conditions outlined above.
Dr. Elena V. SokolovaLead Orthodontist
Saint Petersburg Orthodontic Center
Date: _______________ Alexander D. Petrov
Patient / Client
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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