Patient name

Patient email

Patient phone

CNIC Number

Doctor name

Service --------- Routine Dental Check-Up - $50.00 Scaling and Polishing - $80.00 Teeth Whitening - $200.00 Dental Fillings - $120.00 Root Canal Treatment - $350.00 Wisdom Tooth Extraction - $150.00 Post and Core Build-Up - $180.00 Orthodontic Treatment - $500.00 Crowns and Bridges - $400.00 Gum Disease Treatment - $130.00 Jaw Joint Disorder Therapy - $250.00 Cosmetic Dentistry - $450.00 Nightguard - $90.00

Date

Time