Quotation Estimate Orthodontist in Senegal Dakar –Free Word Template Download with AI

Quotation Estimate No.: QTE-2025-0417
Date of Issue: 15 June 2025
Valid Until: 15 July 2025 Prepared For:
Mr. Moussa Diop
45 Rue Félix Faure, Mermoz
Dakar, Senegal
Tel: +221 77 555 66 77

Dear Mr. Diop,

Thank you for your interest in the orthodontic services provided by our clinic. This Quotation Estimate has been carefully prepared following your initial consultation with our lead Orthodontist, Dr. Aïssatou Ndiaye, on 10 June 2025. Based on the clinical assessment conducted in our Senegal Dakar facility, we are pleased to present the detailed cost breakdown for your recommended orthodontic treatment plan below.

The following Quotation Estimate covers a comprehensive orthodontic treatment program designed to correct mild-to-moderate dental misalignment, improve occlusal function, and enhance the overall aesthetic appearance of your smile. All procedures will be performed by a certified Orthodontist with over fifteen years of clinical experience in the Senegal Dakar region, in full compliance with the standards set by the Senegalese Dental Association and the West African Health Organization.

Ref.	Description of Service	Quantity	Unit Price (XOF)	Total (XOF)
01	Initial orthodontic consultation, clinical examination, and digital panoramic radiograph (OPG)	1 session	45,000	45,000
02	Full intraoral digital impressions and 3D treatment planning by the Orthodontist	1 session	60,000	60,000
03	Custom-fabricated ceramic (tooth-colored) fixed orthodontic brackets – upper and lower arches (32 brackets total)	1 set	380,000	380,000
04	Archwire placement, banding, and initial ligature setup by the Orthodontist	1 session	120,000	120,000
05	Monthly adjustment and monitoring appointments (archwire changes, elastic replacements, progress evaluation)	18 months	35,000	630,000
06	Debonding, polishing, and post-orthodontic evaluation by the Orthodontist	1 session	85,000	85,000
07	Removable retainer fabrication (upper and lower) – Essix type	1 set	95,000	95,000
08	Post-treatment follow-up visits (3-month, 6-month, and 12-month check-ups)	3 visits	25,000	75,000
09	Emergency orthodontic adjustments (broken bracket, wire irritation) – included in plan	Up to 3	20,000	60,000
Subtotal				1,550,000 XOF
VAT (18% – Senegalese Tax Code)				279,000 XOF
Grand Total				1,829,000 XOF

Note: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. Prices are quoted in West African CFA Francs (XOF). Any additional procedures not listed above (e.g., extractions, periodontal therapy, or orthognathic referral) will be subject to a separate supplementary Quotation Estimate issued by the Orthodontist prior to commencement.

The total amount of 1,829,000 XOF may be settled according to the following schedule, as agreed upon during your consultation with our Orthodontist in Senegal Dakar:

Installment	Due Date	Amount (XOF)
Deposit (upon acceptance of this Quotation Estimate)	15 June 2025	365,800
Second installment (at bracket placement)	1 July 2025	548,700
Third installment (month 6 of treatment)	1 January 2026	457,250
Final installment (at debonding)	1 July 2026	457,250

Accepted payment methods include bank transfer (Bank of Africa, Coris Bank, or Ecobank Senegal), mobile money (Orange Money, Wave, Free Money), and cash at our Senegal Dakar clinic. A receipt will be issued for every payment received.

This Quotation Estimate is a non-binding proposal and does not constitute a contractual obligation until formally accepted in writing by the patient and countersigned by the Orthodontist.
The estimated treatment duration of eighteen (18) months is an approximation. The Orthodontist reserves the right to adjust the timeline based on clinical progress observed during monthly reviews in Senegal Dakar.
The patient agrees to attend all scheduled appointments. Missed appointments without prior notice (minimum 48 hours) may incur a rescheduling fee of 15,000 XOF.
Proper oral hygiene maintenance is the patient's responsibility. Failure to maintain adequate hygiene may result in additional periodontal treatment costs not covered by this Quotation Estimate.
In the event of appliance damage caused by the patient (e.g., biting hard objects), repair costs will be billed separately at the standard rate of 25,000 XOF per incident.
All personal health data collected during the orthodontic process is protected under the Senegalese Data Protection Law (Law No. 2016-10) and will not be disclosed to third parties without written consent.
This Quotation Estimate supersedes all prior verbal or written estimates. Any modifications must be documented in a written addendum signed by both parties.
Disputes arising from this Quotation Estimate shall be resolved amicably or, failing that, through the competent courts of Dakar, Senegal.

By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the proposed orthodontic treatment plan, and authorizes the Orthodontist at Dakar Smile Orthodontic Center, Senegal Dakar, to proceed with the services described herein.

Patient Signature
Name: Moussa Diop
Date: _______________ Orthodontist / Clinic Representative
Name: Dr. Aïssatou Ndiaye
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX

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