Quotation Estimate Orthodontist in United States San Francisco –Free Word Template Download with AI

Dear Mr. Mitchell,

Thank you for selecting the Golden Gate Orthodontic Center for your orthodontic care in San Francisco, United States. Following your comprehensive consultation and diagnostic evaluation conducted on June 5, 2025, our orthodontist team has prepared this detailed Quotation Estimate outlining the full scope of treatment, associated costs, and projected timeline for your orthodontic correction. This document serves as a formal Quotation Estimate and does not constitute a binding contract until accepted in writing by both parties.

• Initial Deposit: 20% of the patient responsibility amount ($911.00) due upon acceptance of this Quotation Estimate and prior to the first orthodontic placement appointment.
• Monthly Installments: The remaining balance shall be divided into 18 equal monthly payments of approximately $214.17, due on the 1st of each month, aligned with your orthodontic adjustment visits.
• Accepted Payment Methods: Credit card (Visa, Mastercard, American Express), debit card, ACH bank transfer, HSA/FSA cards, and in-house financing through CareCredit or Sunbit.
• Late Payment: A 1.5% monthly finance charge will apply to any balance not paid within 15 days of the due date, in accordance with California Civil Code Section 1677.
• Insurance Coordination: Our office will submit all orthodontic claims directly to Delta Dental of California. The patient is responsible for any co-pays, deductibles, or amounts exceeding the insurance benefit at the time of service.

• This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date, the orthodontist team reserves the right to revise pricing based on current San Francisco, United States market rates.
• The estimated treatment duration of 18 months is a projection based on the initial diagnostic assessment. Actual orthodontic treatment time may vary depending on individual biological response, compliance with elastic and retainer wear instructions, and any unforeseen clinical developments.
• Should the patient discontinue orthodontic treatment before completion, a non-refundable fee of $500.00 will be assessed to cover the cost of bracket removal, polishing, and final documentation.
• All orthodontic services will be performed by Dr. Elena Vasquez or a credentialed orthodontist associate at the Golden Gate Orthodontic Center located in San Francisco, California, United States.
• This Quotation Estimate does not guarantee specific aesthetic outcomes. The orthodontist will make reasonable clinical efforts to achieve the planned alignment, but individual results may vary.
• By signing below, the patient acknowledges receipt and understanding of this Quotation Estimate and agrees to the payment terms outlined herein. This document does not constitute a guarantee of insurance coverage.