Patient Case Evaluation Form and Medical & Financial Offer

Please review the details of this medical and financial offer carefully. This offer is valid for 30 days only from the issue date.

Section 1: Patient Information

Full Name

Section 2: Medical Evaluation

1. Proposed Services:
3. Bone condition evaluation:
4. Gum condition evaluation:

Section 3: Financial Offer

Detailed cost of services

Tooth extraction

Dental implants

Zircon / Porcelain crowns

Other services

Enter the total discount as a whole number percentage (e.g. 10 = 10%). Leave 0 for no discount.
Note: Cash payment includes a 12% discount.

Section 4: Payment Method

1. Payment options:

Section 5: Treatment Warranty

We provide a treatment warranty under the following terms:

  • Implants: 5-year warranty.
  • Porcelain crowns: 5-year warranty.
  • Zircon crowns: 10-year warranty.

Conditions required to obtain the warranty:

  1. Commit to visiting the clinic for routine check-ups every 6 months.
  2. Maintain oral hygiene and use dental floss and mouthwash regularly.
  3. Avoid excessive chewing of very hard materials that may cause tooth fracture.
  4. Stop smoking or reduce it according to the doctor’s recommendations.
  5. Report any problems immediately and return to the clinic.
  6. Follow all medical instructions provided by the clinic.

Section 6: Offer Terms & Conditions

Offer Terms & Conditions:

  • This offer is valid for 30 days only from the issue date.
  • Any changes in the treatment plan may lead to a cost adjustment.
  • Final agreement is confirmed after the offer is signed by both parties.
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