Quotation Estimate Orthodontist in United States Houston –Free Word Template Download with AI
4820 Westheimer Road, Suite 310, Houston, Texas 77056, United States
Phone: (713) 555-0142 | Email: [email protected]
Texas State License No. TX-ORTHO-2019-4471
Serving Greater Houston, United States Quotation EstimatePatient Information
Name: Jordan A. Mitchell
Date of Birth: March 14, 2003
Address: 2215 Memorial Drive, Apt 7B, Houston, TX 77007, United States
Phone: (832) 555-8891
Insurance Provider: Delta Dental of Texas
Policy Number: DDT-2024-7834561
Quotation Details
Quotation No.: QTE-2025-00487
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Prepared By: Dr. Elena Vasquez, DDS, MS – Lead Orthodontist
Consultation Date: June 5, 2025
Diagnosis Code: ICD-10 K07.32 (Malocclusion)
Following a comprehensive clinical examination, digital panoramic radiography, intraoral scanning, and cephalometric analysis performed at our Houston, United States clinic, the undersigned Orthodontist has determined that the patient requires a full-course orthodontic intervention. This Quotation Estimate outlines all anticipated procedures, materials, and professional fees associated with the recommended treatment plan. All pricing reflects current 2025 fee schedules for orthodontic services in the Houston metropolitan area and complies with the Texas State Board of Dental Examiners regulations.
| Item No. | Description of Orthodontic Service | Frequency | Unit Price (USD) | Estimated Total (USD) |
|---|---|---|---|---|
| 1 | Initial Consultation, Digital Records & Treatment Planning (includes panoramic X-ray, cephalometric X-ray, intraoral 3D scan, and clinical photographs) | One-time | $350.00 | $350.00 |
| 2 | Comprehensive Orthodontic Treatment – Ceramic Braces (upper and lower arches), including bracket bonding, archwire placement, and elastic ligatures | One-time | $5,800.00 | $5,800.00 |
| 3 | Monthly Adjustment & Progression Appointments (archwire changes, elastic adjustments, bracket repositioning as needed) | 18 months | $125.00 | $2,250.00 |
| 4 | Interproximal Reduction (IPR) – selective enamel stripping for space creation | As needed (est. 4 visits) | $85.00 | $340.00 |
| 5 | Removable Retainer Fabrication (Hawley type, upper and lower) – post-debonding phase | One-time | $450.00 | $450.00 |
| 6 | Fixed Lingual Retainer (lower arch, bonded wire) – post-debonding phase | One-time | $380.00 | $380.00 |
| 7 | Emergency / Breakage Appointments (wire adjustment, bracket re-cementation, elastic replacement) | Est. 3 visits | $95.00 | $285.00 |
| 8 | Final Records, Post-Treatment Radiographs & Retention Follow-Up (12 months of check-ups) | One-time + 4 visits | $275.00 | $275.00 |
| TOTAL ESTIMATED COST (Before Insurance) | $10,130.00 | |||
| Estimated Insurance Coverage (Delta Dental of Texas – 50% orthodontic benefit, lifetime maximum $2,000) | -$2,000.00 | |||
| PATIENT RESPONSIBLE BALANCE (Estimated) | $8,130.00 | |||
This Quotation Estimate from our Orthodontist practice in Houston, United States, may be satisfied through the following payment arrangements. A 20% deposit of the patient-responsible balance ($1,626.00) is due at the time of treatment acceptance to secure the patient's appointment slot. The remaining balance may be paid in equal monthly installments over the 18-month treatment duration, or the patient may elect our in-house 0% interest financing plan spread over 24 months. Third-party financing through CareCredit and Sunbit is also available at our Houston clinic. All payments are subject to the terms outlined in our Patient Financial Agreement.
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date, fees may be adjusted to reflect current orthodontic service pricing in the Houston, United States market.
- The total treatment cost is an estimate based on the current clinical findings. The treating Orthodontist reserves the right to modify the treatment plan if additional procedures become clinically necessary, in which case a revised Quotation Estimate will be provided in writing prior to any additional work.
- Insurance coverage amounts are estimates based on the patient's current policy with Delta Dental of Texas. The practice is not responsible for changes in insurance benefits, pre-authorization denials, or adjustments made by the insurance carrier. The patient is ultimately responsible for any balance not covered by insurance.
- Treatment duration is estimated at eighteen (18) months. Early completion or extension of treatment will be prorated accordingly. Monthly adjustment fees will only be charged for actual visits performed.
- This Quotation Estimate does not include the cost of any pre-existing dental restorations, extractions, periodontal treatment, or general dental work that may be required prior to or during orthodontic treatment. Such services will be quoted separately by the referring general dentist or periodontist in the Houston area.
- All orthodontic appliances, brackets, wires, and retainers are the property of Bayou City Orthodontic Associates until the full treatment balance is paid in accordance with the agreed-upon payment schedule.
- This document is governed by the laws of the State of Texas, United States. Any disputes arising from this Quotation Estimate shall be subject to the jurisdiction of the Harris County courts in Houston, Texas.
- The patient acknowledges that they have received a copy of this Quotation Estimate and have had the opportunity to ask questions regarding the scope, cost, and alternatives to the proposed orthodontic treatment.
Dr. Elena Vasquez, DDS, MS
Bayou City Orthodontic Associates
Date: _______________ Patient / Guardian Signature
Jordan A. Mitchell (or Legal Guardian)
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT