Quotation Estimate Orthodontist in United States Chicago –Free Word Template Download with AI
Lakeview Orthodontic Associates, P.C. | 2145 N. Lakeview Avenue, Suite 300, Chicago, Illinois 60614, United States
Phone: (312) 555-0187 | Fax: (312) 555-0188 | Email: [email protected]
Illinois State Board of Dentistry License No. 19-48276 | NPI: 1457892346
Patient Information
| Patient Name: | Jonathan R. Whitfield |
| Date of Birth: | March 22, 2008 (Age: 17) |
| Address: | 1892 W. Diversey Parkway, Apt 4B, Chicago, IL 60642, United States |
| Primary Insurance: | Aetna Dental PPO – Member ID: AET-78234561 |
| Referring Dentist: | Dr. Samuel Okafor, DDS – Lincoln Park Family Dental, Chicago, IL |
Diagnosis and Treatment Plan Summary
Following a comprehensive orthodontic consultation conducted on June 5, 2025, at our Chicago, Illinois practice, the patient presents with a Class II malocclusion, moderate crowding of the anterior maxillary and mandibular segments, a 4 mm overjet, and a crossbite on the left posterior quadrant. The recommended treatment plan involves fixed appliance orthodontics (conventional metal brackets) with an estimated treatment duration of 24 to 30 months. This Quotation Estimate outlines all anticipated costs for the full course of orthodontic care to be delivered at our United States Chicago location.
Itemized Quotation Estimate – Orthodontic Services
| # | Service Description | CPT / ADA Code | Estimated Cost (USD) | Insurance Estimate (USD) |
|---|---|---|---|---|
| 1 | Initial Orthodontic Consultation, Records (Panoramic X-ray, Cephalometric X-ray, Intraoral Photographs, Digital Impressions), and Treatment Planning | D0021 / D0067 / D0186 | $485.00 | $0.00 (100% Patient) |
| 2 | Comprehensive Orthodontic Treatment – Fixed Appliance (Metal Brackets, Upper and Lower Arches), including all monthly adjustments, wire changes, elastic replacements, and routine monitoring over 24–30 months | D0720 / D0730 | $6,800.00 | $3,400.00 (50% PPO) |
| 3 | Interproximal Reduction (IPR) – Up to 12 surfaces for crowding relief | D0730 (included) | $350.00 | $175.00 (50% PPO) |
| 4 | Extraction of Teeth #3 and #15 (Premolar Extractions for Space Creation) | D7240 × 2 | $620.00 | $310.00 (50% PPO) |
| 5 | Post-Orthodontic Retention – Fixed Lingual Retainer (Upper) and Removable Essix Retainer (Lower), including 6-month and 12-month follow-up checks | D0760 / D0762 | $780.00 | $390.00 (50% PPO) |
| 6 | Emergency / Breakage Visits (Estimated 2 visits for bracket re-cementation or wire adjustment) | D0730 | $200.00 | $100.00 (50% PPO) |
| 7 | Final Records and Discharge (Post-treatment X-rays, Photographs, and Digital Scan for Retention Monitoring) | D0186 / D0067 | $225.00 | $0.00 (100% Patient) |
| TOTAL ESTIMATED COST (Patient Responsibility After Insurance) | $4,540.00 | $4,360.00 (Insurance Portion) | ||
| GRAND TOTAL QUOTATION ESTIMATE | $8,900.00 | |||
Payment Terms and Financing Options
This Quotation Estimate for orthodontic services at our Chicago, United States practice may be satisfied through the following payment arrangements:
| Option | Details |
|---|---|
| Full Payment | 10% discount applied to the patient-responsibility portion. Due prior to appliance placement. |
| Monthly Installment Plan | 24 equal monthly payments of approximately $189.17 (patient portion). No interest. First payment due at appliance placement. |
| Third-Party Financing (CareCredit / Sunbit) | 0% APR for 12 months or 6.99% APR for 24–60 months, subject to credit approval. Available at our Chicago office. |
| Insurance Reimbursement | Our billing office in Chicago, IL will submit all claims directly to Aetna Dental PPO. Patient is responsible for the co-pay and any amounts exceeding the annual orthodontic maximum ($3,400). |
Terms and Conditions
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After expiration, a revised estimate reflecting current orthodontic fee schedules in the Chicago, Illinois market will be required.
- All orthodontic treatment described herein will be performed at our licensed practice located at 2145 N. Lakeview Avenue, Chicago, Illinois 60614, United States, in compliance with the Illinois Dental Practice Act and all applicable federal regulations.
- The patient or legal guardian acknowledges that orthodontic treatment outcomes are not guaranteed and that the duration of treatment may extend beyond the estimated 24–30 months based on individual biological response.
- Missed appointments will be subject to a $75.00 no-show fee. Two consecutive missed appointments may result in a re-evaluation of the treatment plan and a revised Quotation Estimate.
- This Quotation Estimate does not constitute a binding contract. A separate Informed Consent and Treatment Agreement must be executed prior to the initiation of any orthodontic procedure.
- All records, radiographs, and digital impressions generated during treatment remain the property of Lakeview Orthodontic Associates, P.C., Chicago, IL, and may be released to the patient or a designated provider upon written request in accordance with HIPAA regulations.
- In the event of treatment interruption exceeding 90 days, a re-entry fee of $250.00 will apply, and a new Quotation Estimate will be issued.
- This practice is located in the United States of America, State of Illinois, City of Chicago, and all services are governed by Illinois state law and the American Association of Orthodontists (AAO) standards of care.
Acceptance and Authorization
By signing below, the patient or legal guardian acknowledges receipt of this Quotation Estimate for orthodontic services in Chicago, Illinois, United States, and authorizes the practice to proceed with the described treatment plan subject to the terms outlined above. This signature does not obligate the patient to begin treatment until a formal Treatment Agreement is signed.
Patient / Legal Guardian SignatureJonathan R. Whitfield (or Guardian: _______________) Date
_________________________ Orthodontist – Lakeview Orthodontic Associates, P.C.
Dr. Margaret L. Chen, DMD, MS Date
_________________________ ⬇️ Download as DOCX Edit online as DOCX
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