Purchase Order Ophthalmologist in Belgium Brussels –Free Word Template Download with AI
MediSight Brussels Ophthalmology Group
12 Avenue Louise, 1050 Brussels, Belgium
VAT No.: BE 0765.432.109 | RIB: BE68 5390 0754 7034
Tel: +32 2 512 3456 | Email: [email protected]
| Company Name: | Clinique Oculaire du Sablon – Ophthalmologist Practice |
| Lead Ophthalmologist: | Dr. Marie-Christine Van den Berg, MD, PhD in Ophthalmology |
| Address: | 45 Rue du Sablon, 1000 Brussels, Belgium |
| VAT No.: | BE 0871.234.567 |
| Contact: | Dr. Van den Berg | +32 2 215 6789 | [email protected] |
| Specialty: | Comprehensive Ophthalmology – Cataract Surgery, Retinal Disorders, Glaucoma Management, and Corneal Transplantation |
| Entity: | MediSight Brussels Ophthalmology Group – Procurement Department |
| Address: | 12 Avenue Louise, 1050 Brussels, Belgium |
| Attn: | Mr. Johan Peeters, Head of Procurement |
| Ref | Description | Qty | Unit | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|---|
| 01 | Comprehensive ophthalmological examination and diagnostic workup (visual acuity, intraocular pressure, fundoscopy, OCT imaging) – performed by the Ophthalmologist at the Brussels clinic | 120 | Patients | €185.00 | €22,200.00 |
| 02 | Phacoemulsification cataract surgery with premium intraocular lens implantation – surgical procedure conducted by the Ophthalmologist and supporting team | 45 | Procedures | €2,450.00 | €110,250.00 |
| 03 | Anti-VEGF intravitreal injection therapy for age-related macular degeneration – administered by the Ophthalmologist | 80 | Injections | €620.00 | €49,600.00 |
| 04 | Corneal topography and pachymetry screening package – diagnostic service provided at the Ophthalmologist's facility in Belgium Brussels | 200 | Sessions | €95.00 | €19,000.00 |
| 05 | Post-operative follow-up consultations (3 visits per patient) – managed by the Ophthalmologist and resident ophthalmic nurses | 135 | Consultations | €75.00 | €10,125.00 |
| 06 | Supply of premium intraocular lenses (IOLs) – AcrySof IQ Vivity, 23.0D – delivered to the Ophthalmologist's operating theatre in Brussels | 45 | Units | €380.00 | €17,100.00 |
| 07 | Consumables: sterile surgical drapes, speculums, sutures, and topical anaesthetic agents for the Ophthalmologist's surgical suite | 1 | Lot | €4,850.00 | €4,850.00 |
| 08 | Emergency on-call ophthalmology coverage (24/7) – the Ophthalmologist provides standby availability for urgent referrals across Belgium Brussels | 3 | Months | €3,200.00 | €9,600.00 |
Subtotal: €242,725.00
VAT (21% – Belgian standard rate): €50,972.25
Grand Total: €293,697.25
- This Purchase Order is issued in accordance with the Belgian Code of Economic Law and applicable EU medical service regulations. All services rendered by the Ophthalmologist shall comply with the standards set by the Belgian Federal Agency for Medicines and Health Products (FAMHP).
- The Ophthalmologist and all associated clinical staff must hold valid Belgian medical licences and professional indemnity insurance covering a minimum liability of €5,000,000 per claim.
- Payment shall be made within thirty (30) calendar days of receipt of a valid invoice from the Ophthalmologist's practice, via bank transfer to the RIB specified in the vendor section. Late payments shall accrue interest at the rate prescribed by the Belgian Law of 2 April 1991 on late payment in commercial transactions.
- All patient data processed in connection with this Purchase Order shall be handled in strict compliance with the General Data Protection Regulation (GDPR) and the Belgian Data Protection Act of 30 July 2018. The Ophthalmologist acts as a data processor under the data processing agreement referenced in Annex B.
- Delivery of all physical supplies (IOLs, consumables) shall be made to the Ophthalmologist's clinic at 45 Rue du Sablon, 1000 Brussels, Belgium, between 08:00 and 17:00 CET, Monday through Friday.
- The Ophthalmologist guarantees that all surgical and diagnostic procedures listed in this Purchase Order will be performed in accordance with the latest clinical guidelines published by the Belgian Society of Ophthalmology (BSO) and the European Society of Ophthalmology (EURETINA).
- Any modification to the scope, quantity, or timing of services under this Purchase Order must be approved in writing by both parties. Verbal authorisations are not valid under Belgian commercial law.
- In the event of a dispute arising from this Purchase Order, the parties agree to first attempt mediation through the Chamber of Commerce of Belgium Brussels. Failing resolution within sixty (60) days, the matter shall be submitted to the competent courts of Brussels, Belgium.
- This Purchase Order is valid for a period of twelve (12) months from the date of issue, unless terminated earlier by mutual written agreement or in accordance with the termination clauses of the master service agreement (MSA-2024-BRU-012).
For and on behalf of the Purchasing Entity:
MediSight Brussels Ophthalmology Group
Johan PeetersHead of Procurement
Date: 14 June 2025
For and on behalf of the Ophthalmologist / Service Provider:
Clinique Oculaire du Sablon
Dr. Marie-Christine Van den Berg, MD, PhDLead Ophthalmologist
Date: 14 June 2025 ⬇️ Download as DOCX Edit online as DOCX
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