Quotation Estimate Orthodontist in Sudan Khartoum –Free Word Template Download with AI
Nile Orthodontic & Dental Clinic — Sudan Khartoum
Clinic Address:El-Rashid Street, Omdurman District
Khartoum, Sudan
Tel: +249-183-XXXXXX
Email: [email protected] Quotation Reference: QE-2025-KRT-0472
Date of Issue: 15 June 2025
Valid Until: 15 July 2025
Prepared By: Dr. Ahmed El-Tahir, Lead Orthodontist 1. Client / Patient Information Patient Name: [Full Name to be inserted] National ID / Passport No.: [To be inserted] Contact Number: [To be inserted] Residential Area, Khartoum: [To be inserted] Referring Physician (if any): [To be inserted] Preferred Treatment Window: [To be inserted] 2. Purpose and Scope of This Quotation Estimate
This Quotation Estimate has been prepared by the Nile Orthodontic & Dental Clinic, a licensed and accredited Orthodontist practice operating in Sudan Khartoum, to provide the patient and/or their legal guardian with a comprehensive, transparent, and itemized financial projection for the proposed orthodontic treatment plan. The scope of this document covers all diagnostic procedures, appliance fabrication, clinical sessions, follow-up appointments, and ancillary services required to achieve the desired orthodontic outcome. All pricing is quoted in Sudanese Pounds (SDG) and reflects the current market rates applicable to orthodontic care in the Khartoum metropolitan area as of the date of issue.
The treating Orthodontist, Dr. Ahmed El-Tahir, holds a Master of Science in Orthodontics from the University of Khartoum and has over fourteen years of clinical experience serving patients across Sudan Khartoum and the surrounding states. This Quotation Estimate is based on a preliminary clinical examination, panoramic radiograph (OPG), intraoral photographs, and digital study models obtained during the initial consultation session.
3. Itemized Treatment Plan and Cost Breakdown| No. | Service / Procedure | Frequency / Qty | Unit Price (SDG) | Subtotal (SDG) |
|---|---|---|---|---|
| 1 | Initial Comprehensive Orthodontic Consultation & Diagnostic Workup (OPG, cephalometric X-ray, intraoral scans, study models) | 1 session | 12,500 | 12,500 |
| 2 | Pre-orthodontic Periodontal & Restorative Treatment (scaling, fillings, extraction of 2 premolars if indicated) | 1 package | 45,000 | 45,000 |
| 3 | Fabrication & Bonding of Fixed Metal Braces (upper and lower arches, 14 brackets per arch, archwires, ligatures, molar bands) | 1 set | 180,000 | 180,000 |
| 4 | Monthly Orthodontic Adjustment & Wire Change Sessions (active treatment phase) | 18 months | 8,500 | 153,000 |
| 5 | Elastic Band & Auxiliary Appliance Supply (interarch elastics, power chain, headgear if required) | 18 months | 3,200 | 57,600 |
| 6 | Debonding, Finishing, & Polishing of Braces | 1 session | 25,000 | 25,000 |
| 7 | Retention Phase: Fabrication & Fitting of Fixed Lingual Retainers (upper & lower) + Removable Acrylic Retainers | 1 set | 38,000 | 38,000 |
| 8 | Post-Retention Follow-Up Reviews (6-month intervals for 2 years) | 4 visits | 5,000 | 20,000 |
| 9 | Emergency Orthodontic Appointments (broken wire, debonded bracket, soft-tissue irritation) — included allowance | Up to 3 visits | 4,500 | 13,500 |
| GRAND TOTAL (Quotation Estimate) | 544,600 SDG | |||
- Deposit (upon acceptance of this Quotation Estimate): 25% of the Grand Total, payable within 7 calendar days of signing. This secures the patient's place in the Orthodontist's treatment roster in Sudan Khartoum.
- Second Installment (at the time of brace bonding): 35% of the Grand Total.
- Monthly Installments (during active treatment): The remaining 40% shall be divided equally across the 18 active treatment months and due on the 5th of each month.
- Accepted Payment Methods: Bank transfer (National Bank of Sudan, Bank of Khartoum, or Sudanese Commercial Bank), mobile money (Fawri, M-Pesa Sudan), or cash at the clinic reception in Khartoum.
- Late Payment: A surcharge of 2% per month will apply to any outstanding balance exceeding 15 days past due. Treatment may be paused at the Orthodontist's discretion if payments remain overdue for more than 30 days.
- This Quotation Estimate is valid for a period of thirty (30) days from the date of issue. After this period, prices may be revised to reflect changes in material costs, currency fluctuation, or updated fee schedules of the Orthodontist practice in Sudan Khartoum.
- The treatment plan outlined herein is based on the clinical findings at the time of the initial examination. The Orthodontist reserves the right to modify the plan if intra-operative findings necessitate additional or alternative procedures. Any such modifications will be communicated in writing and a revised Quotation Estimate will be provided before proceeding.
- The patient agrees to attend all scheduled adjustment appointments. Missed appointments without prior 48-hour notice will incur a no-show fee of 3,000 SDG per occurrence.
- The patient is responsible for maintaining oral hygiene throughout the treatment. Failure to do so may result in decalcification, gingival inflammation, or treatment delays, for which the Orthodontist assumes no financial liability.
- Warranty: The Orthodontist guarantees the integrity of bonded brackets and archwires for a period of 30 days from the date of bonding. Repairs within this window are covered at no additional cost. Repairs beyond this period are subject to the emergency visit fee listed in Item 9.
- This Quotation Estimate does not constitute a contract until signed and countersigned by both parties and the initial deposit is received in full.
- Disputes arising from this Quotation Estimate shall be resolved in accordance with the laws of the Republic of Sudan, with jurisdiction vested in the courts of Khartoum.
By signing below, the patient (or legal guardian) acknowledges having received, read, and understood this Quotation Estimate for Orthodontist services provided by the Nile Orthodontic & Dental Clinic in Sudan Khartoum. The patient confirms that all costs, payment terms, and clinical expectations have been explained satisfactorily and agrees to proceed with the proposed treatment plan.
Patient / Legal Guardian SignatureName: _________________________
Date: _________________________
Nile Orthodontic & Dental Clinic
Khartoum, Sudan
Date: _________________________
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