Quotation Estimate Orthodontist in Thailand Bangkok –Free Word Template Download with AI

Quotation Estimate No.: QTE-2025-0387
Date of Issue: 14 June 2025
Valid Until: 14 July 2025 Prepared For: Mr. Daniel R. Whitfield
Address: 45/12 Sukhumvit 31, Khlong Toei Nuea, Bangkok 10110, Thailand
Contact: +66 (0) 89 442 1176

Dear Mr. Whitfield,

Thank you for your consultation with our senior Orthodontist, Dr. Ananya Chaiyaporn, at our Thailand Bangkok clinic on 10 June 2025. Following a comprehensive clinical examination, digital panoramic radiography, intraoral scanning, and a detailed discussion of your treatment objectives, we are pleased to present this formal Quotation Estimate for your complete orthodontic treatment plan. This document outlines all anticipated costs, treatment phases, and associated services to be delivered at our Thailand Bangkok facility.

Scope of Orthodontist Treatment Services

The following Quotation Estimate covers a full-course orthodontic treatment program as recommended by our Orthodontist team. All procedures will be performed in accordance with the standards set by the Thai Ministry of Public Health and the Thai Society of Orthodontists. Treatment will take place exclusively at our licensed Thailand Bangkok clinic located in the Khlong Toei district.

Itemized Cost Breakdown

No.	Description of Service	Frequency / Duration	Unit Price (THB)	Total (THB)
1	Initial Orthodontist Consultation, Digital Records & Treatment Planning	One-time	3,500	3,500
2	Full-Mouth Digital Panoramic X-Ray & Cephalometric Analysis	One-time	2,800	2,800
3	Intraoral 3D Scanning & Digital Treatment Simulation (ClinCheck)	One-time	4,200	4,200
4	Custom Ceramic Braces Fabrication & Bonding (Upper & Lower Arch)	One-time	85,000	85,000
5	Monthly Orthodontist Adjustment Appointments (wire changes, elastics, minor tooth movement)	18 months	2,500	45,000
6	Interproximal Reduction (IPR) – up to 12 surfaces	As required	800	9,600
7	Removable Retainer Fabrication (Hawley type, Upper & Lower)	One-time	6,500	6,500
8	Post-Treatment Orthodontist Review & Retainer Adjustment (12 months)	4 visits	1,500	6,000
9	Emergency Orthodontist Visit (broken bracket, wire irritation) – up to 3 visits	As needed	1,200	3,600
10	Final Debonding, Polishing & Post-Treatment Photography	One-time	3,000	3,000
Subtotal				169,200
VAT 7% (Thailand Value Added Tax)				11,844
Grand Total				181,044

Payment Schedule

This Quotation Estimate from our Thailand Bangkok orthodontic practice accepts the following payment arrangements:

Deposit (30%): THB 54,313 – due upon acceptance of this Quotation Estimate and prior to the first bonding appointment.
Monthly Installments (70%): THB 12,673 per month over 18 months, payable on the 1st of each calendar month.
Accepted payment methods: Bank transfer (Siam Commercial Bank, Bangkok), credit/debit card (Visa, Mastercard), and cash. A 2% surcharge applies to card payments.

Terms and Conditions

This Quotation Estimate is valid for 30 calendar days from the date of issue. After expiry, pricing may be subject to revision based on material costs and the prevailing exchange rate in Thailand.
All orthodontic treatment will be supervised by Dr. Ananya Chaiyaporn, a board-certified Orthodontist registered with the Thai Medical Council (License No. 11-4-58291).
The estimated treatment duration of 18 months is an approximation. Actual duration may vary by 1–3 months depending on individual tooth response, patient compliance with elastics, and any unforeseen clinical adjustments determined by the Orthodontist.
Missed appointments must be rescheduled at least 48 hours in advance. No-shows will incur a fee of THB 1,000 per occurrence.
This Quotation Estimate does not include general dental treatments (fillings, extractions, periodontal therapy) that may be required prior to or during orthodontic treatment. Such services will be quoted separately by the treating dentist.
The patient is responsible for maintaining oral hygiene and attending all scheduled Orthodontist appointments at the Thailand Bangkok clinic. Failure to comply with treatment instructions may extend the treatment period and is not covered under this estimate.
A written warranty of 12 months is provided on all orthodontic appliances against manufacturing defects. Normal wear and tear, damage from trauma, or damage due to non-compliance is excluded.
This Quotation Estimate is issued in accordance with Thai consumer protection regulations and the Thai Medical Council's guidelines for orthodontic practice in Bangkok, Thailand.

Acceptance

By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the scope of Orthodontist services to be provided at the Thailand Bangkok clinic, and agrees to the payment schedule and terms outlined above.

Patient Signature
Mr. Daniel R. Whitfield
Date: _______________ Authorized Representative
Dr. Ananya Chaiyaporn, Orthodontist
Siam Smile Orthodontic Center, Bangkok, Thailand
Date: _______________ Note: This Quotation Estimate is a good-faith estimate of costs and is not a fixed-price contract. The final invoice may differ by up to 10% if additional clinical interventions are deemed necessary by the treating Orthodontist during the course of treatment. All prices are quoted in Thai Baht (THB). For international patients, our Thailand Bangkok front desk can assist with currency conversion and multi-currency payment processing. Please retain this document for your records. ⬇️ Download as DOCX Edit online as DOCX

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