Quotation Estimate Orthodontist in Vietnam Ho Chi Minh City –Free Word Template Download with AI

Quotation No.: QTE-2025-HCM-0487
Date Issued: 15 June 2025
Valid Until: 15 July 2025 Prepared For: Mr. Nguyen Van Minh
Address: 45 Le Duan Street, District 3,
Vietnam Ho Chi Minh City
Contact: +84 912 345 678 Prepared By: Dr. Tran Thi Lan
Position: Lead Orthodontist
License No.: VN-OD-2019-0342

1. Introduction and Scope of Services

This Quotation Estimate has been prepared by Sai Gon Orthodontic & Dental Center, a licensed and accredited orthodontic practice located in the heart of Vietnam Ho Chi Minh City, to provide Mr. Nguyen Van Minh with a comprehensive and transparent breakdown of all anticipated costs associated with his orthodontic treatment plan. As a specialist Orthodontist with over fifteen years of clinical experience serving patients across Vietnam Ho Chi Minh City and the surrounding southern provinces, Dr. Tran Thi Lan and her team are committed to delivering world-class orthodontic care at competitive and clearly itemized rates.

The following Quotation Estimate covers the full course of orthodontic treatment, including initial diagnostic assessments, appliance fabrication, all scheduled adjustment appointments, retention phase services, and any ancillary procedures deemed necessary by the treating Orthodontist to achieve optimal dental alignment and occlusal harmony. All pricing is quoted in Vietnamese Dong (VND) and reflects the current fee schedule of our clinic in Vietnam Ho Chi Minh City as of the date of issue.

2. Itemized Cost Breakdown

No.	Service / Procedure	Frequency	Unit Price (VND)	Total (VND)	Notes
1	Initial Orthodontic Consultation & Diagnostic Workup (X-rays, 3D CBCT scan, intraoral photography, digital impressions)	One-time	3,500,000	3,500,000	Includes full treatment plan
2	Fixed Ceramic Braces – Upper & Lower Arch (appliance placement)	One-time	45,000,000	45,000,000	3M Clarity brackets
3	Monthly Orthodontic Adjustment Appointments	22 months	1,200,000	26,400,000	Every 4–6 weeks
4	Interproximal Reduction (IPR) – as required by Orthodontist	Up to 4 sessions	800,000	3,200,000	Contingent on case
5	Elastics, O-rings & Auxiliary Components (monthly supply)	22 months	350,000	7,700,000	Replaced each visit
6	Debonding & Finishing (removal of brackets, polishing, occlusal adjustment)	One-time	5,000,000	5,000,000	Includes final X-ray
7	Fixed Retainer (upper & lower) + 2 Removable Retainers (Hawley type)	One-time	8,500,000	8,500,000	12-month supply
8	Post-Treatment Retention Check-ups (every 3 months for 12 months)	4 visits	500,000	2,000,000	Monitoring stability
9	Emergency / Unscheduled Visit (bracket re-cementation, wire adjustment)	Up to 3 visits	600,000	1,800,000	Contingency allowance
GRAND TOTAL (VND)				103,100,000

3. Payment Schedule

In accordance with the standard payment policy of our Orthodontist practice in Vietnam Ho Chi Minh City, the total Quotation Estimate amount may be settled through the following installment plan:

Installment	Due Date	Amount (VND)	Percentage
1st – Deposit (upon signing)	15 June 2025	25,775,000	25%
2nd – Mid-treatment	15 December 2025	25,775,000	25%
3rd – Pre-debonding	15 June 2026	25,775,000	25%
4th – Final (retention phase)	15 September 2026	25,775,000	25%

4. Terms and Conditions

This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiry date, the Orthodontist reserves the right to revise pricing based on updated material costs or changes in the Vietnam Ho Chi Minh City healthcare fee schedule.
All prices are inclusive of VAT (10%) as mandated by the Vietnam Ministry of Finance. No additional hidden charges will be applied beyond those itemized in this document.
The treating Orthodontist may, at her clinical discretion, recommend additional procedures not listed herein if the patient's condition warrants it. Any such additions will be communicated in writing and require the patient's explicit consent before proceeding.
Appointment cancellations must be made at least forty-eight (48) hours in advance. Late cancellations or no-shows will incur a fee of 500,000 VND per occurrence.
The total treatment duration of approximately twenty-two (22) months is an estimate. The actual timeline may vary depending on the patient's biological response, compliance with elastics and oral hygiene instructions, and the clinical judgment of the Orthodontist.
This Quotation Estimate does not cover general dental treatments (fillings, extractions, periodontal therapy) unless explicitly stated. Such services will be quoted separately by the general dentist on staff.
Payment may be made via bank transfer, cash, or major credit cards. A 2% surcharge applies to credit card transactions exceeding 10,000,000 VND per transaction.
In the event of a dispute, both parties agree to resolve matters amicably. If unresolved, the matter shall be submitted to the Vietnam Ho Chi Minh City People's Court for adjudication under Vietnamese law.
Our clinic operates Monday through Saturday, 8:00 AM to 5:30 PM. Emergency orthodontic consultations are available by phone at +84 28 3822 4567 for patients residing in Vietnam Ho Chi Minh City.

Important Note: This Quotation Estimate is a good-faith projection of costs based on the current clinical assessment. The final invoice may differ slightly if the Orthodontist determines, during the course of treatment, that the scope of work requires modification. Any such changes will be documented in a supplementary addendum signed by both parties.

5. Acceptance and Authorization

By signing below, the patient acknowledges that this Quotation Estimate has been reviewed, all terms and conditions have been understood, and the patient consents to proceed with the orthodontic treatment plan as outlined by the Orthodontist at Sai Gon Orthodontic & Dental Center, Vietnam Ho Chi Minh City.

Patient Signature
Mr. Nguyen Van Minh
Date: _______________ Orthodontist / Clinic Representative
Dr. Tran Thi Lan
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX

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