Quotation Estimate Orthodontist in Sri Lanka Colombo –Free Word Template Download with AI
Dental & Orthodontic Centre of Excellence
No. 42, Galle Road, Colombo 03, Sri Lanka Colombo
Tel: +94 11 234 5678 | Email: [email protected]
1. Introduction and Purpose of This Quotation Estimate
This Quotation Estimate has been prepared by our licensed Orthodontist team at the Dental & Orthodontic Centre of Excellence, located in the heart of Sri Lanka Colombo, to provide Mr. R. Perera with a comprehensive and transparent breakdown of all anticipated costs associated with his orthodontic treatment plan. As a leading Orthodontist practice in Sri Lanka Colombo, we are committed to delivering world-class dental care while ensuring full financial transparency for every patient. This Quotation Estimate covers the complete duration of treatment, including initial consultations, diagnostic imaging, appliance fabrication, regular adjustment appointments, and final retention.
2. Patient and Clinical Summary
Following a thorough clinical examination conducted by our senior Orthodontist, Dr. Nimali Fernando (LDS, MOrth, Colombo), the patient has been diagnosed with Class II malocclusion with moderate crowding in the anterior maxillary and mandibular arches. The recommended treatment protocol involves fixed orthodontic appliances (metal brackets) on both arches, with an estimated treatment duration of 24 to 30 months. All diagnostic work, including panoramic radiographs, cephalometric analysis, intraoral impressions, and digital smile design, has been completed at our Sri Lanka Colombo clinic.
3. Detailed Cost Breakdown
| Item No. | Description of Service | Frequency | Unit Cost (LKR) | Total (LKR) |
|---|---|---|---|---|
| 01 | Initial Consultation & Comprehensive Orthodontic Assessment by Senior Orthodontist | One-time | 8,500 | 8,500 |
| 02 | Diagnostic Imaging (OPG, Cephalometric X-ray, Digital Intraoral Scans) | One-time | 12,000 | 12,000 |
| 03 | Pre-treatment Orthodontic Records (Impressions, Photographs, Model Analysis) | One-time | 6,500 | 6,500 |
| 04 | Fixed Metal Bracket Appliance – Upper Arch (14 brackets + bands + wires) | One-time | 85,000 | 85,000 |
| 05 | Fixed Metal Bracket Appliance – Lower Arch (14 brackets + bands + wires) | One-time | 85,000 | 85,000 |
| 06 | Monthly Adjustment & Wire Change Appointments (Orthodontist visit) | 28 months | 5,500 | 154,000 |
| 07 | Interproximal Reduction (IPR) – as clinically indicated | As needed | 3,000 | 12,000 |
| 08 | Post-treatment Retainers (Hawley type, upper & lower) | One-time | 18,000 | 18,000 |
| 09 | Post-treatment Review & Retainer Adjustments (12 months) | 4 visits | 3,500 | 14,000 |
| 10 | Emergency Appointments (bracket debonding, wire adjustment) – estimated | 2 visits | 4,000 | 8,000 |
| GRAND TOTAL (Inclusive of all professional fees) | 403,000 | |||
4. Payment Terms and Schedule
This Quotation Estimate from our Orthodontist practice in Sri Lanka Colombo offers the following flexible payment options to accommodate the patient's financial planning:
- Option A – Full Payment: 10% discount applied upon full payment at the time of appliance bonding. Revised total: LKR 362,700.
- Option B – Installment Plan: 25% deposit at bonding, followed by 24 equal monthly installments of LKR 14,292. No additional interest is charged.
- Option C – Hybrid Plan: 50% at bonding, 25% at mid-treatment (month 14), and 25% at debonding.
All payments may be made via bank transfer to our Sri Lanka Colombo office account, cash, or major credit/debit cards. A receipt will be issued for every transaction in compliance with Sri Lankan tax regulations.
5. Terms, Conditions, and Important Notes
Important: This Quotation Estimate is valid for 30 days from the date of issue. The final treatment cost may vary by up to 10% depending on clinical developments during the course of orthodontic therapy. Any additional procedures not listed herein (e.g., extractions, surgical coordination, or extended treatment beyond 30 months) will be communicated in writing by the treating Orthodontist prior to commencement, with a revised Quotation Estimate provided for the patient's approval.
The patient is responsible for maintaining oral hygiene throughout treatment. Failure to attend scheduled appointments at our Sri Lanka Colombo clinic may result in a rescheduling fee of LKR 2,500 per missed visit. This Quotation Estimate does not cover general dental treatments such as fillings, root canal therapy, or periodontal therapy, which will be quoted separately if required.
6. Scope of Professional Services
As a registered and licensed Orthodontist operating in Sri Lanka Colombo, our practice adheres to the standards set by the Dental Council of Sri Lanka and the Sri Lankan Orthodontic Society. All treatments are performed using internationally certified materials sourced from reputable manufacturers. The Quotation Estimate provided herein reflects the current market rates in Sri Lanka Colombo as of June 2025 and includes all professional fees, material costs, and laboratory charges. Our Orthodontist team guarantees a minimum of 24 months of active treatment with a 12-month post-treatment retention follow-up period, all encompassed within this Quotation Estimate.
7. Acceptance and Authorization
By signing below, the patient acknowledges receipt of this Quotation Estimate and agrees to the terms and conditions outlined above. The treating Orthodontist confirms that the clinical plan and cost projections are accurate to the best of professional judgment based on the current clinical findings in Sri Lanka Colombo.
Patient SignatureName: Mr. R. Perera
Date: _______________ Orthodontist / Authorizing Practitioner
Dr. Nimali Fernando, LDS, MOrth
Dental & Orthodontic Centre, Colombo
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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