Quotation Estimate Orthodontist in Uzbekistan Tashkent –Free Word Template Download with AI
Orthodontist Professional Services — Uzbekistan Tashkent
Document Ref: QE-ORT-TSK-2025-0472
1. Client Information
2. Scope of Orthodontist Services
4. Terms and Conditions of This Quotation Estimate
Name: ________________________
Date: ________________________ Orthodontist / Clinic Representative
Dr. Aziz Karimov, DMD
License No.: UZ-ORT-2011-0384
Date: ________________________ ⬇️ Download as DOCX Edit online as DOCX
| Field | Details |
|---|---|
| Patient Name: | ____________________________ |
| Passport / ID No.: | ____________________________ |
| Residential Address: | Tashkent, Uzbekistan |
| Contact Number: | ____________________________ |
| Referring Physician: | ____________________________ |
This Quotation Estimate is issued by our licensed Orthodontist practice located in Uzbekistan Tashkent to provide a comprehensive, itemized breakdown of all anticipated orthodontic treatment costs. The services outlined below are based on a preliminary clinical examination and radiographic assessment conducted at our clinic on Amir Temur Avenue. All procedures will be performed by a board-certified Orthodontist with over fifteen years of clinical experience in the Tashkent region.
3. Itemized Cost Breakdown| # | Service / Procedure | Quantity | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|
| 1 | Initial Orthodontist Consultation & Clinical Examination | 1 session | $45.00 | $45.00 |
| 2 | Full Panoramic X-Ray (OPG) & Cephalometric Radiograph | 1 set | $35.00 | $35.00 |
| 3 | Digital Intraoral Scanning & 3D Treatment Planning | 1 session | $60.00 | $60.00 |
| 4 | Comprehensive Orthodontic Treatment Plan (Written Report) | 1 document | $30.00 | $30.00 |
| 5 | Placement of Metal Brackets (Upper & Lower Arch, 28 brackets) | 28 units | $12.00 | $336.00 |
| 6 | Archwire Fitting & Initial Banding (Nickel-Titanium 0.014") | 2 arches | $85.00 | $170.00 |
| 7 | Monthly Orthodontist Adjustment Visits (12 months) | 12 visits | $55.00 | $660.00 |
| 8 | Interproximal Reduction (IPR) & Elastics (as required) | Est. 4 sessions | $40.00 | $160.00 |
| 9 | Debonding, Finishing & Polishing | 1 session | $120.00 | $120.00 |
| 10 | Fixed Retainer (Upper & Lower) + Removable Retainer (2 units) | 1 set | $180.00 | $180.00 |
| 11 | Post-Treatment Follow-Up & Retainer Check (6 months) | 2 visits | $35.00 | $70.00 |
| TOTAL ESTIMATED COST | $2,966.00 | |||
| TOTAL IN UZBEKISTAN SOM (UZS) (Rate: 1 USD = 12,800 UZS) | 37,964,800 UZS | |||
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, prices may be subject to revision based on material costs and exchange rate fluctuations in Uzbekistan Tashkent.
- All orthodontic procedures will be carried out by a licensed Orthodontist registered with the Ministry of Health of the Republic of Uzbekistan. The treating Orthodontist holds a valid medical license and is a member of the Uzbekistan Dental Association.
- The total treatment duration is estimated at fourteen (14) to eighteen (18) months, depending on individual case complexity. The Orthodontist will reassess progress at each monthly visit and may adjust the treatment plan accordingly.
- Payment may be made in full at the time of bracket placement, or in three equal installments: 40% at the initial appointment, 30% at the six-month mark, and 30% upon debonding. Payment in Uzbekistan Som (UZS) or US Dollars (USD) is accepted at the prevailing Central Bank of Uzbekistan exchange rate on the day of transaction.
- A non-refundable deposit of 20% of the total Quotation Estimate amount is required to secure the patient's appointment slot and reserve materials.
- Any additional procedures not listed in this Quotation Estimate (e.g., extraction of impacted teeth, periodontal therapy, or emergency repairs) will be quoted separately in writing before commencement.
- The patient is responsible for maintaining oral hygiene and attending all scheduled Orthodontist appointments. Missed appointments exceeding two consecutive visits may result in a rescheduling fee of $25.00 per occurrence.
- This Quotation Estimate does not constitute a guarantee of specific aesthetic outcomes. The Orthodontist will use best clinical judgment and standard-of-care protocols throughout the treatment in Uzbekistan Tashkent.
- All medical records, radiographs, and digital scans generated during treatment remain the property of the clinic. The patient may request a copy of records at any time for a nominal administrative fee.
- In the event of a dispute, matters shall be resolved in accordance with the Civil Code of the Republic of Uzbekistan and the regulations of the Tashkent City Health Department.
By signing below, the patient (or legal guardian) acknowledges receipt of this Quotation Estimate for Orthodontist services in Uzbekistan Tashkent, agrees to the terms and conditions outlined above, and authorizes the clinic to proceed with the described treatment plan.
Patient / Legal Guardian SignatureName: ________________________
Date: ________________________ Orthodontist / Clinic Representative
Dr. Aziz Karimov, DMD
License No.: UZ-ORT-2011-0384
Date: ________________________ ⬇️ Download as DOCX Edit online as DOCX
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