Purchase Order Ophthalmologist in United States Chicago –Free Word Template Download with AI
Ophthalmology Department — United States Chicago
Buyer / Receiving Party
Chicago Lakeside Ophthalmology Center
2345 North Michigan Avenue, Suite 800
Chicago, Illinois 60614, United States
Phone: (312) 555-0198
Email: [email protected]
Tax ID / EIN: 36-4829175
PO No.: CL-2025-04782
Date of Issue: June 12, 2025
Required Delivery Date: July 15, 2025
Payment Terms: Net 30 Days
Shipping Method: Ground Freight (UPS)
Incoterms: DDP Chicago, IL
Seller / Supplier
MedVision Ophthalmic Supply Co., LLC
1120 West Cermak Road, Building C
Chicago, Illinois 60608, United States
Phone: (773) 555-0442
Email: [email protected]
Tax ID / EIN: 36-7712034
This Purchase Order is issued by Chicago Lakeside Ophthalmology Center, a licensed ophthalmology practice located in the United States Chicago metropolitan area, for the procurement of specialized ophthalmic diagnostic equipment, surgical instruments, and recurring consumable supplies. This Purchase Order is intended to support the operational needs of our board-certified Ophthalmologist team, who provide comprehensive eye care services including cataract surgery, LASIK procedures, retinal diagnostics, and glaucoma management to patients across the Chicago, Illinois region. All items listed herein must comply with the Food and Drug Administration (FDA) regulations applicable in the United States and must meet the clinical standards expected by the Illinois Department of Public Health for ophthalmic practices operating in the United States Chicago area.
| Item # | Description | Qty | Unit | Unit Price (USD) | Extended Price (USD) |
|---|---|---|---|---|---|
| 001 | Zeiss Visucam 500 Digital Fundus Camera — Ophthalmologist-grade retinal imaging system with 500-megapixel sensor, 45°/30°/25° fields of view, and integrated OCT module for comprehensive retinal assessment in the United States Chicago clinic. | 1 | Unit | $48,750.00 | $48,750.00 |
| 002 | Alcon Centurion Phacoemulsification System — Complete surgical platform for cataract extraction procedures performed by the Ophthalmologist team, including foot pedal, handpiece, and irrigation/aspiration cartridges. | 1 | Unit | $32,400.00 | $32,400.00 |
| 003 | Topcon iTrace Wavefront Aberrometer — Advanced corneal topography and wavefront analysis device for pre-operative LASIK and refractive surgery planning by the Ophthalmologist. | 1 | Unit | $27,900.00 | $27,900.00 |
| 004 | Disposable Intraocular Lens (IOL) — Alcon AcrySof IQ SN60WF, 20.0 D, for cataract surgery. Bulk order for the Ophthalmologist surgical schedule in the United States Chicago facility. | 500 | Units | $187.50 | $93,750.00 |
| 005 | Phacoemulsification Tips — Alcon Centurion 2.75 mm disposable tips, compatible with the Ophthalmologist surgical workflow. | 2,000 | Units | $12.30 | $24,600.00 |
| 006 | Topical Anesthetic Drops — Proparacaine HCl 0.5%, 15 mL vials, for pre-operative patient preparation by the Ophthalmologist in the United States Chicago operating suite. | 200 | Vials | $8.75 | $1,750.00 |
| 007 | Post-Operative Steroid/Antibiotic Eye Drops — Prednisolone Acetate 1% combined with Tobramycin 0.4%, 10 mL bottles, for the Ophthalmologist post-surgical care protocol. | 300 | Bottles | $14.20 | $4,260.00 |
| 008 | Annual Preventive Maintenance Contract — Covers all ophthalmic diagnostic and surgical equipment installed at the United States Chicago location, including 4 on-site service visits per year by certified biomedical technicians. | 1 | Year | $12,500.00 | $12,500.00 |
| 009 | Training & Calibration Service — On-site training for the Ophthalmologist staff and nursing team on the Zeiss Visucam 500 and Topcon iTrace systems, including initial calibration and software licensing for 3 years. | 1 | Service | $6,800.00 | $6,800.00 |
| 010 | Shipping, Handling & Installation — Crated freight delivery to the United States Chicago facility, white-glove installation, and on-site commissioning of all capital equipment. | 1 | Lot | $4,350.00 | $4,350.00 |
| Subtotal | $257,360.00 |
| Illinois State Sales Tax (8.75%) | $22,519.00 |
| Chicago Municipal Tax (2.5%) | $6,434.00 |
| Grand Total (USD) | $286,313.00 |
4.1 This Purchase Order is governed by the laws of the State of Illinois and the United States. Any disputes arising from this Purchase Order shall be resolved in the federal or state courts located in Cook County, United States Chicago, Illinois.
4.2 All ophthalmic equipment and supplies must be FDA-cleared or FDA-approved prior to delivery. The supplier shall provide certificates of conformity, lot numbers, and expiration dates for all consumable items delivered to the Ophthalmologist practice.
4.3 Delivery shall be made to the receiving dock at 2345 North Michigan Avenue, Chicago, Illinois 60614, United States. The supplier is responsible for all freight charges, insurance, and risk of loss until the goods are accepted by the Ophthalmologist facility manager.
4.4 Payment shall be remitted via ACH transfer to the supplier's designated bank account within thirty (30) calendar days of the invoice date, provided that all items have been inspected and accepted by the Ophthalmologist department head.
4.5 The supplier warrants that all capital equipment is free from defects in materials and workmanship for a period of twenty-four (24) months from the date of installation. Consumable items are warranted to be unexpired for a minimum of eighteen (18) months from the date of delivery.
4.6 This Purchase Order may be amended only by written mutual agreement signed by authorized representatives of both parties. No oral modifications shall be binding.
4.7 The supplier shall maintain professional liability insurance of no less than $5,000,000 per occurrence for the duration of this Purchase Order and any associated service contracts.
NOTE: All equipment must be installed and calibrated in the presence of the lead Ophthalmologist or a designated senior associate at the United States Chicago facility. A signed installation acceptance form must be completed before the Purchase Order is considered fulfilled. The Ophthalmologist team reserves the right to reject any item that does not meet the specifications outlined in this Purchase Order or that fails to comply with current FDA and Illinois state regulatory requirements.For the Buyer — Chicago Lakeside Ophthalmology Center
Signature: ______________________________
Name: Dr. Margaret A. Sullivan, MD, FACS
Title: Lead Ophthalmologist & Medical Director
Date: ______________________________
For the Supplier — MedVision Ophthalmic Supply Co., LLC
Signature: ______________________________
Name: James R. Whitfield
Title: Vice President, Sales & Account Management
Date: ______________________________
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