Quotation Estimate Dietitian in United States Houston –Free Word Template Download with AI
4820 Westheimer Road, Suite 310, Houston, Texas 77056, United States
Phone: (713) 555-0142 | Email: [email protected]
Texas State Board of Dietetics License No. TX-D-2024-08871
Quotation EstimateQuotation Details
Quotation No.: QTE-HOU-2025-0417
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Prepared By: Dr. Elena Vasquez, RD, LD
Dietitian Services – Houston, TXClient Information
Client Name: Mr. Jonathan R. Whitfield
Address: 2214 Memorial Drive, Houston, TX 77007, United States
Phone: (281) 555-0398
Email: [email protected]
Insurance Ref.: Aetna PPO #AET-4472-881
1. Purpose of This Quotation EstimateThis Quotation Estimate is issued by GreenPath Nutrition & Wellness Center, a licensed and accredited Dietitian practice operating in Houston, Texas, United States, to provide Mr. Jonathan R. Whitfield with a comprehensive, itemized breakdown of the professional Dietitian services requested. This document serves as a formal cost projection and is not a binding contract until signed and accepted by both parties. All pricing reflects the current 2025 fee schedule for Dietitian consultations and nutritional therapy programs delivered within the Houston metropolitan area, United States.
2. Scope of Dietitian ServicesThe following Dietitian services have been requested and are included in this Quotation Estimate. All services will be performed by a Registered Dietitian (RD) or Licensed Dietitian (LD) in compliance with the Texas Occupations Code, Chapter 672, and the standards set forth by the Academy of Nutrition and Dietetics. The practice location is in the Greater Houston area, United States, and all in-person sessions will take place at our Westheimer Road office unless otherwise noted.
| # | Service Description | Duration / Frequency | Unit Rate (USD) | Quantity | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Initial Comprehensive Nutritional Assessment – A full intake interview, medical history review, body composition analysis, and dietary recall conducted by a board-certified Dietitian in Houston, United States. | 90 minutes / One-time | $225.00 | 1 | $225.00 |
| 2 | Personalized Meal Planning & Dietary Prescription – Customized nutrition plan tailored to the client's health goals, including macronutrient breakdown, grocery lists, and recipe guidance. | 60 minutes / One-time | $150.00 | 1 | $150.00 |
| 3 | Follow-Up Dietitian Consultation – Progress monitoring, plan adjustments, and ongoing nutritional counseling. Conducted at the Houston, TX office or via telehealth. | 45 minutes / Weekly | $125.00 | 8 | $1,000.00 |
| 4 | Laboratory Work Interpretation & Nutritional Correlation – Review of blood panels, metabolic markers, and micronutrient levels with a Dietitian to correlate findings with dietary recommendations. | 30 minutes / One-time | $95.00 | 2 | $190.00 |
| 5 | Specialized Dietary Program – Type 2 Diabetes Management – Structured 12-week program including carbohydrate counting education, glycemic index guidance, and bi-weekly Dietitian check-ins. | 12 weeks / Bi-weekly | $110.00 | 6 | $660.00 |
| 6 | Nutritional Education Workshop – Group session (up to 8 participants) on Mediterranean diet principles, local Houston grocery sourcing, and sustainable eating habits. | 2 hours / One-time | $350.00 | 1 | $350.00 |
| 7 | Telehealth Dietitian Consultation – Remote follow-up via secure video platform for clients in the Houston, United States area who prefer virtual sessions. | 30 minutes / As needed | $85.00 | 4 | $340.00 |
| 8 | Nutritionist Report & Documentation – Written summary of all Dietitian interventions, progress notes, and recommendations for the client's primary care physician in Houston, TX. | One-time | $75.00 | 1 | $75.00 |
| Subtotal (All Dietitian Services) | $3,990.00 |
| Applicable Texas Sales Tax (8.25% – Harris County, Houston, United States) | $329.18 |
| Insurance Reimbursement Estimate (Aetna PPO – 80% coverage after deductible) | –$2,793.00 |
| Estimated Client Out-of-Pocket Balance | $1,526.18 |
4.1 Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, pricing for Dietitian services in Houston, United States, may be subject to revision based on updated fee schedules.
4.2 Payment Schedule: The initial assessment fee is due at the time of the first appointment. Remaining balances for the 12-week program are payable in two installments: 50% at week 1 and 50% at week 7. Telehealth and workshop fees are due prior to the scheduled session.
4.3 Cancellation Policy: Appointments must be cancelled at least 24 hours in advance. Late cancellations or no-shows will incur a 50% fee of the scheduled Dietitian session rate.
4.4 Insurance: GreenPath Nutrition & Wellness Center accepts Aetna, Cigna, UnitedHealthcare, and BCBS Texas. The client is responsible for verifying coverage, deductibles, and copay amounts directly with their insurer. This Quotation Estimate does not guarantee insurance reimbursement.
4.5 Scope of Practice: All services are provided by a Registered Dietitian or Licensed Dietitian as defined under Texas law. The Dietitian does not prescribe medication, perform surgical procedures, or replace the client's primary care physician. Referrals to other Houston, United States healthcare providers may be made when clinically appropriate.
4.6 Confidentiality: All client information is protected under HIPAA (Health Insurance Portability and Accountability Act) and Texas state privacy statutes. Records are retained for a minimum of seven (7) years in compliance with United States federal and Texas state regulations.
4.7 Governing Law: This Quotation Estimate and any resulting service agreement shall be governed by the laws of the State of Texas, United States. Any disputes shall be resolved in the courts of Harris County, Houston, Texas.
5. AcceptanceBy signing below, the client acknowledges receipt of this Quotation Estimate for Dietitian services in Houston, United States, and agrees to the terms, conditions, and pricing outlined herein. The client confirms that they have had the opportunity to ask questions regarding the scope of services, the qualifications of the Dietitian, and the estimated costs before providing consent.
Client Signature & DateMr. Jonathan R. Whitfield
Dietitian / Authorized RepresentativeDr. Elena Vasquez, RD, LD
GreenPath Nutrition & Wellness Center
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