Dental cost estimates and informed financial consent, signed online
Fees by stage, what isn't included, your own insurance wording and an expiry date, acknowledged and signed by the patient before treatment starts.
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QuoteCloud puts the estimate of fees and the patient's consent in one document: fees by stage with your own treatment codes, what the estimate doesn't include, your own wording about insurers, an expiry date, then acknowledgements the patient ticks in a Forms block with locked wording, and their signature.
Helen Gordon's estimate of fees from a fictional practice, Wrenfield Dental Group, as a printed statement. Each stage line is stamped in turn: clean and X-rays $260, filling and root canal $1,625, crowns in zirconia $3,900, replacing 36 with an implant and crown $5,450; estimated total $11,235.00, valid until Wed 18 Nov 2026. Then four acknowledgements tick in a Forms block with locked wording, Helen's signature draws and a stamp lands: signed, $2,247.00 deposit paid via Stripe.
The estimate and the consent, read part by part
The back half of Helen's plan, as she read it before signing. Each part is a block in the practice's treatment plan template.
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Follows the choices
Fees by stage, for the options chosen
One row per stage with the alternative Helen chose, the estimated total and the deposit paid on signing. Change an option and every figure follows, so the signed estimate matches the treatment agreed.
Wrenfield Dental GroupTreatment plan & estimate of fees WD-T-2214 Sample · fictional businessEstimate of fees
Estimated fees by stage Stage 1 Clean & X-rays $260.00 Stage 2 Filling & root canal $1,625.00 Stage 3 CrownsZirconia $3,900.00 Stage 4 Replacing 36Implant & crown $5,450.00 Optional $0.00 Estimated total $11,235.00 Paid on signing · 20% deposit $2,247.00 -
Practice edits
What isn't included, in your words
Specialist referrals, hospital or anaesthetist fees, and your own wording about insurers and paying for treatment. QuoteCloud never calculates an insurance benefit, and any payment plan is your text about a provider you work with.
Not included
- Specialist referrals, if your dentist suggests one
- Hospital or anaesthetist fees
- Treatment not listed in this plan
Your insurer Practice's wording
Your insurer decides what it pays back. Ask your insurer what it covers for this treatment: no insurance benefit is included or calculated in this estimate.
Paying for your treatment Practice's wording
Your deposit is paid when you sign. Each later stage is billed by the practice when it is done. If you'd like to spread the cost, ask reception about the payment plan providers we work with: any plan is arranged with that provider.
Valid until Wed 18 Nov 2026. The expiry date is set on the document; after it, the practice sends a new plan.
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Locked block
Acknowledgements no one can reword
Four statements as Forms block checkboxes inside a locked block, then Helen's signature and the 20% deposit through Stripe. The wording is your practice's own: QuoteCloud doesn't give medical or legal advice.
Forms block and content locking: Business
Before you go ahead
Forms block Locked wording
Please read and tick each statement. Dr Qureshi went through these with you at your consultation.
- My dentist explained this plan, the options in it and the other choices I have, and answered my questions. (ticked)
- I understand these are estimated fees. If the plan changes, the practice sends me a revised plan to sign. (ticked)
- I understand no insurance benefit is included or calculated here, and I can ask my insurer what it covers. (ticked)
- I understand this plan is valid until Wed 18 Nov 2026. (ticked)
- Helen GordonPatient SignedTue 20 Oct, 7:52 pm
Deposit to book your first visits · 20%
$2,247.00
Paid via Stripe
Certificate of authenticity and audit trail attached to the signed plan.
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Questions answered before signing
Helen asked about the bridge in a comment, and the coordinator replied in the plan. The thread stays with the document.
Notes from the practice
- Your dentist is Dr Hamza Qureshi. Bec, our treatment coordinator, books each visit with you.
- The weeks shown are our planning: we confirm each date with you.
- If the plan changes at a visit, we send you a revised plan to sign before we go on.
Helen GordonIf I choose the bridge instead, do the teeth either side need crowns?
Bec, Wrenfield DentalYes: a bridge is held by crowns on 35 and 37, which is why it's priced as three units. Happy to talk it through on the phone.
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A record of each step
Opened, comment added, choices kept, acknowledgements ticked, signed and paid. The signed PDF, certificate of authenticity and audit trail are your practice's record.
Activity
- Plan openedHelen Gordon, the evening after her visit
- Comment addedAsked about the bridge option
- Implant & crown keptZirconia crowns kept on 46 and 26
- Acknowledgements ticked4 of 4, in the Forms block
- Signed by HelenCertificate of authenticity attached
- Deposit paid$2,247.00 via Stripe
The estimate always matches what was chosen
A signed estimate that doesn't match the treatment is the usual gap in informed financial consent. Here the estimate and the plan are one document.
Pick layered ceramic crowns or the partial denture in the plan, or tick the night guard: the stage rows, the estimated total and the deposit in the estimate change with it.
- Stage subtotals and the total in one place
- The deposit as a percentage of the chosen total
- An expiry date set on the document
Price tables: Essentials and up
Multi-stage treatment plansYour treatment, stage by stage
Fees with the practice's own treatment codes.
Stage 1Clean & X-rays$260.00
WD-CL1Scale & clean$180.00
WD-XR1Intraoral X-rays2 × $40$80.00
Stage 2Filling & root canal$1,625.00
WD-FL2Tooth-coloured filling, two surfacesTooth 15$245.00
WD-RC1Root canal treatmentTooth 46$1,380.00
Stage 3CrownsTooth 46, 26$3,900.00
Stage 4Replacing 36Tooth 36$5,450.00
OptionalTick to add$0.00
- Estimated total
- $11,235.00
- Deposit to book your first visits · 20% on signing
- $2,247.00
Treatment codes are your practice's own; QuoteCloud does not connect to any fee schedule.
Estimate of fees
| Stage 1 Clean & X-rays | $260.00 |
|---|---|
| Stage 2 Filling & root canal | $1,625.00 |
| Stage 3 CrownsZirconia | $3,900.00 |
| Stage 4 Replacing 36Implant & crown | $5,450.00 |
| Optional | $0.00 |
| Estimated total | $11,235.00 |
| Paid on signing · 20% deposit | $2,247.00 |
Not included
- Specialist referrals, if your dentist suggests one
- Hospital or anaesthetist fees
- Treatment not listed in this plan
Your insurer Practice's wording
Your insurer decides what it pays back. Ask your insurer what it covers for this treatment: no insurance benefit is included or calculated in this estimate.
Paying for your treatment Practice's wording
Your deposit is paid when you sign. Each later stage is billed by the practice when it is done. If you'd like to spread the cost, ask reception about the payment plan providers we work with: any plan is arranged with that provider.
Valid until Wed 18 Nov 2026. The expiry date is set on the document; after it, the practice sends a new plan.
Consent wording written once, locked in every plan
Save your consent, insurance and payment wording in the content library. Every plan template uses the same blocks, and the locked ones can't be changed plan by plan.
- Consent: restorative & implantsForms block Locked
- Consent: patient under 18Forms block Locked
- Insurance wordingText Locked
- Paying for your treatmentText Locked
- Not included: standardText
- Stage: clean & X-raysPrice table
- 1CoverWritten to the patient
- 2Tooth chart & X-ray
- 3Stage 1: clean & X-rays From library
- 4Later stages & alternativesFrom the fee list
- 5Estimate: not included From library
- 6Your insurer Locked block
- 7Paying for your treatment Locked block
- 8Before you go ahead Locked block
- 9Signature & deposit
One source
Update the wording in the library and new plans use it.
Content library: Essentials and up
Locked blocks
Staff can't edit locked consent or insurance wording in a plan.
Content locking: Business
Ticks inside the plan
Acknowledgements as Forms block fields, ticked before signing.
Forms block: Business
Put your estimate and consent in one document
Free for 14 days, no credit card required. Send us your consent form and we'll convert one template during the trial.
When the patient is under 18
Isla is 14, so her orthodontic plan names her as the patient and her mother, Kate, as the signer. Kate reads the acknowledgements, including that she is Isla's parent or guardian and can agree for her, ticks each one and signs.
Several signers are supported, each with their own signature, if your practice asks for both parents. A signing order isn't set: each signs from their own link.
- The patient and the signer both named
- A guardian acknowledgement in locked wording
- Deposit paid by the parent on signing
Before Isla starts
Forms block Locked wording
Isla is under 18, so a parent or guardian reads, ticks and signs.
Patient: Isla Kowal, 14. Signed by a parent or guardian.
- Dr Dalgaard explained this plan, the options in it and the other choices we have, and answered our questions. (ticked)
- I understand these are estimated fees and that a revised plan is sent to sign if the plan changes. (ticked)
- I understand Isla needs to wear her aligners or look after her braces as the practice explains. (ticked)
- I am Isla's parent or guardian and can agree to this plan for her. (ticked)
- Kate KowalParent or guardian, for Isla Kowal (14) SignedFri 16 Oct, 8:05 pm
Deposit to book Isla's records visit · 20%
$1,586.00
Paid via Stripe
Certificate of authenticity and audit trail attached to the signed plan.
Getting informed financial consent online
From the treatment plan to a signed estimate, acknowledgements and the deposit.
Save your wording
Put your consent, insurance and payment wording in the content library and lock it.
Build the plan
Price each stage from your fee list; the estimate follows the plan.
Set the expiry
Set the date the estimate is valid until.
Send
The patient, or a parent or guardian, opens it on any phone.
Tick, sign, pay
They tick each acknowledgement, sign and pay the deposit.
Estimate and consent questions
Can QuoteCloud handle informed financial consent for dental treatment?
It holds the document: an estimate of fees by stage, what isn't included, your wording about insurers and payment, an expiry date, acknowledgements the patient ticks and their signature, with a certificate of authenticity and an audit trail. The wording and what it must cover are your practice's responsibility; QuoteCloud gives no legal or medical advice.
Can patients tick consent statements before they sign?
Yes, on the Business plan. The Forms block adds checkboxes inside the plan, so each acknowledgement is ticked before signing. Content locking keeps your consent wording in a locked block that staff can't change plan by plan, and the content library holds the same block for every template.
Does QuoteCloud calculate insurance benefits?
No. QuoteCloud doesn't connect to insurers or calculate insurance benefits. Add your own wording that tells patients to ask their insurer what it covers. Treatment codes are your practice's own; QuoteCloud does not connect to any fee schedule, so codes are text from your own fee list.
What happens if the treatment changes after the estimate is signed?
Revise the plan and send the new version for the patient to sign. On the Business plan, version history keeps each earlier version. Your acknowledgements can say that a revised plan is sent to sign whenever the treatment or fees change.
Can we mention payment plans in the estimate?
Only as your own text, for example naming a payment plan provider your practice works with and saying any plan is arranged with them. QuoteCloud takes a deposit or full payment on signing through Stripe or PayPal, and doesn't run instalments, payment plans or reminders.
More for dental practices
Every page of the QuoteCloud dental microsite.
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Multi-stage treatment plans & tooth chartsThe tooth chart, every stage and appointment, and each line priced from your own fee list, in one plan the patient accepts online.Explore
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Deposits on signing for dental treatmentA deposit as a percentage or a fixed amount, paid by card or PayPal the moment the plan is signed. Later stages are billed by your practice.Explore
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Orthodontic plans for aligners & bracesAligners or braces as options, the treatment course and retainers, signed by the patient or a parent or guardian for a minor.Explore
- Implant & oral surgery treatment plansImplant, bridge or denture set out as alternatives, surgical and restorative stages over months, and a deposit to book surgery.
- Cosmetic dentistry quotesVeneers, bonding and whitening options side by side, smile photos in the plan, and a deposit to book the first appointment.
- Periodontal & hygiene treatment plansDeep cleaning by quadrant, review visits and an ongoing maintenance plan, set out as stages the patient signs.
- Check-up & whitening offers sent in bulkOne check-up, hygiene or whitening offer, personalised and bulk-sent to your patient list, then tracked as each is opened and accepted.
- QuoteCloud for dental groups & multi-practice teamsShared plan templates, locked consent wording, a team per practice and approval for large discounts across every location.
- Practice management & accounting integrationsAccepted plans to your practice management software through Zapier or the API, and to Xero or QuickBooks.
- Dental templatesReal QuoteCloud templates for dental treatment plan quotes, treatment consent forms and treatment plan proposals.
- QuoteCloud implementation for dental practicesYour fee list loaded, treatment plan templates converted, consent wording locked and the front desk and clinicians trained.
- FAQAnswers to the questions general, cosmetic, orthodontic, implant and periodontal practices ask most.
Estimate, consent and signature in one link
Free for 14 days. No credit card required.