Quotation Estimate Orthodontist in United Kingdom Birmingham –Free Word Template Download with AI
142 New Street, Birmingham, B2 4HA, United Kingdom
Telephone: 0121 496 0000 | Email: [email protected]
GDC Registered Practice | CQC Registered
Reference: QTE-2025-BHM-0847
Date Issued: 14 June 2025
Valid Until: 14 July 2025
1. Patient / Client Details
Mr. James R. Whitfield
PRV-2025-003841
27 Edgbaston Crescent, Birmingham, B15 2TN, United Kingdom
07700 900123
Dr. Sarah Mitchell, BDS, MOrthRCSEng
AXA Health (Policy No. AXA-9928471)
2. Purpose of This Quotation Estimate
This Quotation Estimate has been prepared by Birmingham Smile Orthodontics, a fully registered orthodontic practice located in the heart of United Kingdom Birmingham, to provide Mr. Whitfield with a comprehensive and transparent breakdown of the anticipated costs associated with his proposed orthodontic treatment plan. As a specialist Orthodontist practice, we are committed to ensuring that every patient in Birmingham and the wider West Midlands region receives clear, itemised financial information before any treatment commences. This document serves as a formal estimate and does not constitute a binding contract until accepted in writing by the patient.
3. Proposed Treatment Plan – Itemised Costs
| Ref | Description of Service | Duration / Frequency | Unit Cost (GBP) | Estimated Total (GBP) |
|---|---|---|---|---|
| 01 | Initial Orthodontic Consultation & Diagnostic Assessment (including panoramic X-ray, intraoral photographs, and digital study models) | One-time | £185.00 | £185.00 |
| 02 | Comprehensive Treatment Planning by Specialist Orthodontist (CBCT scan, cephalometric analysis, and digital treatment simulation) | One-time | £240.00 | £240.00 |
| 03 | Placement of Fixed Ceramic Braces (upper and lower arches, including bonding of brackets, archwires, and elastic ligatures) | One-time | £3,200.00 | £3,200.00 |
| 04 | Monthly Orthodontic Review Appointments (wire changes, elastic adjustments, and progress monitoring by the treating Orthodontist) | 22 months | £95.00 | £2,090.00 |
| 05 | Removal of Fixed Appliances & Bonding of Fixed Retainers (upper and lower arches) | One-time | £450.00 | £450.00 |
| 06 | Removable Essix Retainers (upper and lower, including two sets of replacement retainers over 12 months) | One-time | £520.00 | £520.00 |
| 07 | Emergency / Unscheduled Appointments (estimated allowance for bracket re-bonding, wire adjustments, or urgent orthodontic issues) | Up to 3 visits | £65.00 | £195.00 |
| 08 | Post-Treatment Review & Final Orthodontic Assessment (12-month and 24-month follow-up) | 2 visits | £75.00 | £150.00 |
| Estimated Total Cost of Treatment (excl. VAT where applicable) | £7,030.00 | |||
4. Payment Options Available
As a private Orthodontist practice in United Kingdom Birmingham, we offer flexible payment arrangements to make orthodontic treatment accessible. The following options are available for this Quotation Estimate:
| Option | Details | Monthly Payment (Approx.) |
|---|---|---|
| A – Full Payment | 100% of the total Quotation Estimate amount payable prior to treatment commencement. A 5% discount applies. | £6,678.50 (one-off) |
| B – 12-Month Plan | Interest-free instalments over 12 months. 20% deposit required at booking. | £502.50 |
| C – 24-Month Plan | Interest-free instalments over 24 months. 20% deposit required at booking. | £251.25 |
| D – 36-Month Plan | Interest-free instalments over 36 months. 20% deposit required at booking. | £167.50 |
5. Terms and Conditions
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. Should the patient wish to proceed after the validity period, the Orthodontist reserves the right to re-assess and issue a revised estimate.
- All prices are quoted in British Pounds Sterling (GBP) and are exclusive of any applicable Value Added Tax (VAT), which will be added at the prevailing rate at the time of treatment.
- The estimated treatment duration of twenty-two (22) months is based on clinical assessment. The Orthodontist may, in their professional clinical judgement, extend or shorten the treatment period. Additional monthly review fees will apply for any extension beyond the estimated duration.
- A non-refundable deposit of 20% of the total Quotation Estimate is required to secure the patient's treatment slot and to cover the cost of initial diagnostic work (items 01 and 02).
- Should the patient discontinue treatment before completion, a cancellation fee of 15% of the remaining outstanding balance will be applied, in addition to any fees already incurred for appointments attended.
- This practice operates in full compliance with the General Dental Council (GDC) standards, the Care Quality Commission (CQC) regulations, and all applicable data protection legislation under the UK General Data Protection Regulation (UK GDPR).
- Insurance claims: The patient is responsible for submitting any insurance claims directly to their provider. Birmingham Smile Orthodontics will provide itemised invoices and clinical documentation as required by the insurer.
- Any additional procedures not included in this Quotation Estimate (e.g., orthodontic extractions, periodontal treatment, or restorative work) will be quoted separately and require written patient consent prior to commencement.
- This Quotation Estimate does not form a contract of treatment. A formal Treatment Consent Form and Patient Information Leaflet will be provided prior to the commencement of any orthodontic intervention.
- Complaints regarding this Quotation Estimate or any aspect of the orthodontic treatment should be directed in writing to the Practice Manager at the address stated above. The practice follows the GDC's guidance on handling complaints and is a member of the Local Dental Complaints Procedure.
6. Patient Acknowledgement and Acceptance
By signing below, I, the undersigned patient, confirm that I have received, read, and understood this Quotation Estimate for orthodontic treatment provided by Birmingham Smile Orthodontics in Birmingham, United Kingdom. I acknowledge that the figures presented are estimates and that the final cost may vary depending on clinical circumstances. I accept the terms and conditions outlined in Section 5 of this document.
Patient Signature: Mr. James R. Whitfield
Date: ____________________
Orthodontist / Practice Representative: Dr. Sarah Mitchell, BDS, MOrthRCSEng
Date: ____________________
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