Quotation Estimate Orthodontist in Saudi Arabia Jeddah –Free Word Template Download with AI
Orthodontist Professional Services — Saudi Arabia Jeddah
Patient / Client Details
Name: [Patient Full Name]
National ID / Iqama No.: [ID Number]
Contact Number: +966 5X XXX XXXX
Email: [[email protected]]
Address: Jeddah, Saudi Arabia
Referring Physician / Insurance
Referring Doctor: [Name, if applicable]
Insurance Provider: [Tawuniya / Bupa / Medgulf / Other]
Policy Number: [Policy No.]
Pre-Authorization Ref.: [Ref. No.]
This Quotation Estimate has been prepared by our licensed Orthodontist at Al-Shifa Orthodontic Center, located in the heart of Saudi Arabia Jeddah, to provide a comprehensive and transparent breakdown of all anticipated orthodontic treatment costs. The following services are included based on the clinical assessment conducted on 10 June 2025. All procedures will be performed in strict compliance with the Saudi Food and Drug Authority (SFDA) regulations and the Ministry of Health guidelines governing orthodontic practice in the Kingdom of Saudi Arabia.
| No. | Service / Procedure Description | Quantity | Unit Price (SAR) | Total (SAR) |
|---|---|---|---|---|
| 1 | Initial Orthodontic Consultation & Clinical Examination (including panoramic X-ray, intraoral photographs, and digital study models) | 1 session | 450.00 | 450.00 |
| 2 | Cone Beam Computed Tomography (CBCT) Scan for 3D Orthodontic Planning | 1 scan | 850.00 | 850.00 |
| 3 | Digital Intraoral Scanning & Treatment Plan Formulation by Lead Orthodontist | 1 session | 600.00 | 600.00 |
| 4 | Placement of Self-Ligating Ceramic Braces (Upper & Lower Arch) — including bonding, wire insertion, and initial adjustment | 1 procedure | 12,500.00 | 12,500.00 |
| 5 | Monthly Orthodontic Adjustment & Wire Changes (estimated 18-month treatment duration) | 18 visits | 350.00 | 6,300.00 |
| 6 | Interproximal Reduction (IPR) / Enamel Stripping (if clinically indicated during treatment) | Up to 12 teeth | 150.00 | 1,800.00 |
| 7 | Removable Retainer Fabrication (Hawley type, Upper & Lower) — post-debonding | 2 retainers | 750.00 | 1,500.00 |
| 8 | Post-Treatment Follow-Up Visits (3 months, 6 months, 12 months, 24 months) | 4 visits | 250.00 | 1,000.00 |
| 9 | Emergency Orthodontic Appointment (broken bracket, wire irritation) — included in treatment | Up to 3 visits | 0.00 | 0.00 |
| Subtotal | 25,000.00 | |||
| VAT (15% — Saudi Arabia Value Added Tax) | 3,750.00 | |||
| Grand Total (Incl. VAT) | 28,750.00 SAR | |||
- Down Payment: 30% of the Grand Total (SAR 8,625.00) is due upon acceptance of this Quotation Estimate and prior to the commencement of active orthodontic treatment.
- Installment Plan: The remaining 70% (SAR 20,125.00) may be paid in equal monthly installments over the 18-month treatment period, with no additional interest or processing fees.
- Insurance Coverage: Where applicable, the patient's health insurance provider in Saudi Arabia Jeddah may cover a portion of the orthodontic fees. The patient is responsible for any co-payment or deductible amounts not covered by the policy. Our clinic will submit all necessary pre-authorization forms directly to the insurer.
- Accepted Payment Methods: Bank transfer (STC Pay, Mada, Visa, Mastercard), cash, and insurance direct billing.
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. Prices are subject to revision after the validity period expires.
- All orthodontic procedures will be performed by a board-certified Orthodontist registered with the Saudi Commission for Health Specialties (SCFHS) and licensed to practice in the city of Jeddah, Saudi Arabia.
- The estimated treatment duration of 18 months is an approximation. Actual duration may vary depending on individual biological response, patient compliance with oral hygiene, and adherence to dietary restrictions during treatment.
- Any additional procedures not listed in this Quotation Estimate (e.g., orthognathic surgery referral, additional extractions, or extended treatment beyond 18 months) will be quoted separately with prior written consent from the patient.
- The patient agrees to attend all scheduled adjustment appointments. Missed appointments beyond two consecutive visits may result in a re-scheduling fee of SAR 200.00 per occurrence.
- All materials used (brackets, wires, elastics, retainers) are SFDA-approved and sourced from internationally recognized manufacturers (3M Unitek, Damon Q, or equivalent).
- This Quotation Estimate does not constitute a guarantee of specific aesthetic outcomes. The Orthodontist will use best clinical judgment to achieve the optimal functional and aesthetic result within the scope of the treatment plan.
- Disputes arising from this Quotation Estimate shall be governed by the laws of the Kingdom of Saudi Arabia and shall be subject to the jurisdiction of the competent courts in Jeddah, Saudi Arabia.
By signing below, the patient (or legal guardian) acknowledges having received, read, and understood this Quotation Estimate for Orthodontist services at Al-Shifa Orthodontic Center, Saudi Arabia Jeddah. The patient consents to the proposed treatment plan and agrees to the payment terms and conditions outlined herein.
Patient / Legal Guardian SignatureName: _________________________
Date: _________________________ Orthodontist / Clinic Representative
Dr. Khalid Al-Rashid, DDS, MSc
Al-Shifa Orthodontic Center, Jeddah
Date: _________________________ ⬇️ Download as DOCX Edit online as DOCX
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