Quotation Estimate Orthodontist in Tanzania Dar es Salaam –Free Word Template Download with AI
East Coast Orthodontic & Dental Clinic
Plot 45, Sam Nujoma Street, Mbezi Beach, Tanzania Dar es Salaam
Tel: +255 754 123 456 | Email: [email protected]
License No: TMDA/ORT/2024/0087 | Registered with the Tanzania Medical and Dental Council
Client / Patient Information| Patient Name: Mr. Joseph M. Mushi | National ID No: 19910312-0001-000 |
| Address: House 22, Kariakoo, Tanzania Dar es Salaam | Contact: +255 713 987 654 |
| Referring Physician: Dr. Hassan Juma, General Dentist | Insurance Provider: NIC (National Insurance Fund) |
This Quotation Estimate is issued by our Orthodontist practice located in Tanzania Dar es Salaam to provide a comprehensive, itemized breakdown of the anticipated costs for the full orthodontic treatment plan. The following services have been recommended following a clinical examination, panoramic radiograph (OPG), intraoral photography, and digital study model analysis conducted on 5 June 2025.
| No. | Description of Orthodontist Service | Frequency / Duration | Unit Cost (TZS) | Total Cost (TZS) |
|---|---|---|---|---|
| 1 | Initial Consultation & Comprehensive Orthodontic Assessment (clinical exam, OPG, cephalometric analysis, digital impressions) | One-time | 185,000 | 185,000 |
| 2 | Pre-Orthodontic Treatment: Scaling, polishing, and management of active caries (up to 4 restorations) | One-time | 450,000 | 450,000 |
| 3 | Placement of Fixed Metal Braces (upper and lower arches) – includes brackets, archwires, bands, and bonding | One-time | 2,800,000 | 2,800,000 |
| 4 | Monthly Orthodontist Adjustment Visits (wire changes, elastic replacements, progress monitoring) | 18 months | 120,000 | 2,160,000 |
| 5 | Interproximal Reduction (IPR) / Stripping (if clinically indicated during treatment) | As needed | 85,000 | 340,000 |
| 6 | Removable Retainers (upper and lower) – acrylic with wire, fabricated in-house | One-time | 350,000 | 350,000 |
| 7 | Post-Orthodontic Follow-Up & Retainer Check-ups | 6 months (3 visits) | 75,000 | 225,000 |
| 8 | Emergency Orthodontist Appointment (broken bracket, wire irritation) – up to 2 visits | As needed | 95,000 | 190,000 |
| GRAND TOTAL (TZS) | 6,700,000 | |||
Grand Total in Words: Six Million Seven Hundred Thousand Tanzanian Shillings Only (TZS 6,700,000/=).
Payment Terms & Conditions- A non-refundable deposit of 30% (TZS 2,010,000) is required to confirm the appointment and reserve the treatment slot with our Orthodontist team in Tanzania Dar es Salaam.
- The remaining balance shall be payable in 18 equal monthly installments of TZS 299,444, aligned with each adjustment visit.
- Payment may be made via bank transfer (CRDB Bank, Account No. 0045-8821-3377, East Coast Orthodontic & Dental Clinic), M-Pesa, Tigo Pesa, or cash at the clinic reception.
- This Quotation Estimate is valid for 30 calendar days from the date of issue. Prices are subject to revision upon expiry due to changes in imported orthodontic materials and exchange rate fluctuations.
- All costs are quoted in Tanzanian Shillings (TZS) and are inclusive of VAT at the prevailing rate of 18% as mandated by the Tanzania Revenue Authority (TRA).
- Any additional procedures not listed in this Quotation Estimate (e.g., orthognathic surgery referral, additional extractions, or extended treatment beyond 18 months) will be communicated in writing and require the patient's signed consent before commencement.
- The patient agrees to attend all scheduled Orthodontist adjustment appointments. Missed appointments beyond 7 days without prior notice may incur a rebooking fee of TZS 50,000.
- Our clinic in Tanzania Dar es Salaam operates Monday to Friday, 08:00–17:00, and Saturday, 08:00–13:00. Emergency appointments are available by phone during operating hours.
- This Quotation Estimate does not constitute a binding contract. A formal Treatment Consent Form will be executed prior to the commencement of any orthodontic procedure.
By signing below, the patient acknowledges receipt of this Quotation Estimate for Orthodontist services in Tanzania Dar es Salaam and agrees to the terms and conditions outlined above. The patient confirms that all information provided is accurate and that the treatment plan has been explained in understandable terms.
Patient / Guardian SignatureName: Joseph M. Mushi
Date: ____________________ Orthodontist / Authorized Representative
Name: Dr. Amina Mwakalinga, BDS, MOrth
Date: ____________________ Clinic Stamp & Verification
East Coast Orthodontic & Dental Clinic
Tanzania Dar es Salaam ⬇️ Download as DOCX Edit online as DOCX
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