Quotation Estimate Orthodontist in United Arab Emirates Abu Dhabi –Free Word Template Download with AI
Document Reference: QE-2025-ABD-04872 | Date of Issue: 15 June 2025
United Arab Emirates — Abu DhabiClinic Name: Al Noor Orthodontic & Dental Centre
Address: Al Maryah Island, Tower 3, Level 5, Abu Dhabi, United Arab Emirates
Telephone: +971 2 445 6789 | Email: [email protected]
License No.: DHA-ABD-ORTHO-2019-0342 | Trade License: 1045872
Lead Orthodontist: Dr. Fatima Al Mansoori, BDS, MSc Orthodontics (UAE)
Patient / Client Information
| Field | Details |
|---|---|
| Patient Name | Mr. Ahmed Khalid Al Rashidi |
| Emirates ID No. | 784-1990-1234567-8 |
| Contact Number | +971 50 123 4567 |
| Residence | Al Reem Island, Abu Dhabi, United Arab Emirates |
| Referring Physician | Dr. Omar Haddad, General Dentist, Corniche Dental Clinic, Abu Dhabi |
Scope of Orthodontic Treatment & Quotation Estimate Breakdown
This Quotation Estimate has been prepared by our experienced Orthodontist team at Al Noor Orthodontic & Dental Centre, located in the heart of United Arab Emirates Abu Dhabi, following a comprehensive clinical examination and diagnostic imaging session conducted on 10 June 2025. The Orthodontist, Dr. Fatima Al Mansoori, has assessed the patient's dental and skeletal alignment and recommends a full-course orthodontic intervention. All pricing below is quoted in United Arab Emirates Dirhams (AED) and reflects the current fee schedule approved by the Department of Health – Abu Dhabi (DoH-AD).
| Item No. | Description of Service | Frequency / Duration | Unit Price (AED) | Total (AED) |
|---|---|---|---|---|
| 1 | Initial Orthodontic Consultation & Diagnostic Records (Panoramic X-ray, Cephalometric X-ray, Intraoral Photography, Digital Impression Scan) | One-time | 1,250.00 | 1,250.00 |
| 2 | Orthodontic Treatment Plan Formulation & Patient Counselling Session | One-time | 500.00 | 500.00 |
| 3 | Placement of Self-Ligating Ceramic Brackets (Upper & Lower Arch – 28 brackets total) | One-time | 8,500.00 | 8,500.00 |
| 4 | Archwire Fitting, Ligature Placement & Initial Activation | One-time | 1,800.00 | 1,800.00 |
| 5 | Monthly Orthodontic Adjustment Visits (Archwire changes, Elastics, Progression Checks) | 18 months | 650.00 | 11,700.00 |
| 6 | Interproximal Reduction (IPR) – Selective Enamel Reduction for Space Creation | As required (est. 3 sessions) | 400.00 | 1,200.00 |
| 7 | Removable Retainer Fabrication (Hawley Retainer – Upper & Lower) | One-time (post-debonding) | 1,500.00 | 1,500.00 |
| 8 | Post-Treatment Follow-Up & Retainer Adjustment (6-month interval for 2 years) | 4 visits | 350.00 | 1,400.00 |
| 9 | Emergency Orthodontic Appointment (Broken bracket, wire irritation – up to 2 visits) | As needed | 300.00 | 600.00 |
| Subtotal (AED) | 28,450.00 | |||
| VAT (5% – United Arab Emirates Standard Rate) | 1,422.50 | |||
| GRAND TOTAL (AED) | 29,872.50 | |||
Payment Terms & Conditions
1. This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, the Orthodontist reserves the right to revise pricing due to changes in material costs or regulatory fee adjustments in United Arab Emirates Abu Dhabi.
2. A non-refundable deposit of 20% (AED 5,974.50) is required to secure the patient's treatment slot and commence the orthodontic plan. The remaining balance shall be payable in equal monthly instalments over the 18-month active treatment period.
3. Payment may be made via bank transfer, credit/debit card (Visa, Mastercard, Amex), or cash at the clinic reception. All transactions are processed in compliance with UAE Central Bank regulations.
4. Any additional orthodontic procedures not listed in this Quotation Estimate (e.g., orthognathic surgery referral, additional extractions, or extended treatment beyond 18 months) will be subject to a separate written estimate approved by the treating Orthodontist.
5. The patient acknowledges that orthodontic treatment outcomes are individual and that the estimated duration of 18 months is a clinical projection. The Orthodontist will communicate any necessary timeline adjustments during regular review appointments.
6. This Quotation Estimate does not constitute a guarantee of specific aesthetic or functional outcomes. It represents a professional clinical estimate based on current diagnostic findings in the United Arab Emirates Abu Dhabi healthcare context.
7. The clinic is fully licensed by the Department of Health – Abu Dhabi and the patient's data is handled in accordance with UAE Federal Decree-Law No. 45 of 2021 on Personal Data Protection.
Acceptance & Authorisation
By signing below, the patient confirms that they have received, read, and understood this Quotation Estimate for orthodontic services. The patient agrees to the scope of treatment, the total cost, and the payment schedule as outlined by the Orthodontist at Al Noor Orthodontic & Dental Centre, United Arab Emirates Abu Dhabi.
Patient SignatureName: Mr. Ahmed Khalid Al Rashidi
Date: _______________ Orthodontist / Authorising Clinician
Dr. Fatima Al Mansoori, BDS, MSc Ortho.
License No.: DHA-ABD-ORTHO-2019-0342
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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