Quotation Estimate Doctor General Practitioner in Canada Toronto –Free Word Template Download with AI
1200 Yonge Street, Suite 450, Toronto, Ontario, Canada M4W 1Y8
Phone: (416) 555-0142 | Email: [email protected]
College of Physicians and Surgeons of Ontario (CPSO) License No. 4829173
Quotation EstimateQuotation Details
Quotation No.: QTE-2025-04871
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Prepared By: Dr. Margaret Chen, MD, FRCPC
Practice Location: Canada Toronto, Ontario
Client / Patient Information
Name: [Patient Full Name]
Address: [Street, City, Ontario, Postal Code]
Phone: [Contact Number]
Email: [Email Address]
Insurance Provider: [OHIP / Private Plan]
Policy / Member No.: [Number]
Dear Valued Patient,
Thank you for choosing the Doctor General Practitioner services at our Toronto Family Medicine & General Practice Centre. This Quotation Estimate has been prepared in accordance with the standards set forth by the College of Physicians and Surgeons of Ontario and reflects the current fee schedule for comprehensive primary care services delivered in Canada Toronto. Please review the itemized breakdown below, which outlines the anticipated costs for your scheduled course of treatment and ongoing general practice consultations.
Itemized Services & Estimated Fees| # | Service Description | Fee Code | Qty | Unit Price (CAD) | Estimated Total (CAD) |
|---|---|---|---|---|---|
| 1 | Initial Comprehensive Consultation with Doctor General Practitioner – includes full medical history review, physical examination, and initial treatment plan formulation | K001 | 1 | $125.00 | $125.00 |
| 2 | Follow-up General Practice Consultation (30-minute session) – ongoing management of chronic conditions, medication review, and progress assessment | K002 | 4 | $95.00 | $380.00 |
| 3 | Diagnostic Blood Panel – Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipid Profile, and Thyroid Function Tests ordered by the Doctor General Practitioner | D105 | 1 | $185.00 | $185.00 |
| 4 | Electrocardiogram (ECG/EKG) – 12-lead cardiac screening performed in-clinic in Toronto, Ontario | D210 | 1 | $75.00 | $75.00 |
| 5 | Point-of-Care Testing – Rapid influenza, strep throat, and urinalysis conducted during general practice visits | D305 | 2 | $45.00 | $90.00 |
| 6 | Preventive Health Screening & Wellness Assessment – age-appropriate cancer screening, immunization review, and lifestyle counselling by the Doctor General Practitioner | P100 | 1 | $110.00 | $110.00 |
| 7 | Specialist Referral Coordination – preparation of referral documentation and follow-up communication with specialists within the Canada Toronto healthcare network | R050 | 2 | $55.00 | $110.00 |
| 8 | Telehealth / Virtual General Practice Consultation – secure video consultation with your Doctor General Practitioner for non-urgent follow-ups | T020 | 2 | $70.00 | $140.00 |
| 9 | Prescription Renewal & Medication Management – review, adjustment, and renewal of ongoing prescriptions as directed by the Doctor General Practitioner | M015 | 3 | $35.00 | $105.00 |
| 10 | Administrative & Record-Keeping Fee – maintenance of electronic medical records, billing processing, and correspondence within the Ontario healthcare system | A010 | 1 | $40.00 | $40.00 |
| TOTAL ESTIMATED AMOUNT (CAD) | $1,360.00 | ||||
Please be advised that as a licensed Doctor General Practitioner operating in Canada Toronto, the majority of the services listed above are covered under the Ontario Health Insurance Plan (OHIP). The amounts quoted in this Quotation Estimate represent the standard fee schedule as published by the Ontario Medical Association (OMA). Your out-of-pocket responsibility, if any, will depend on your specific OHIP coverage and any supplementary private insurance plan you may hold. Diagnostic laboratory services (items 3, 4, and 5) are typically fully covered under OHIP for residents of Ontario. Telehealth consultations (item 8) are also covered under OHIP for eligible services. This Quotation Estimate is provided for transparency and budgeting purposes and does not constitute a final invoice.
Terms & Conditions of This Quotation Estimate1. This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issuance. Fees are subject to change in accordance with the OMA Fee Schedule effective as of the date of service delivery in Canada Toronto.
2. All services will be performed by or under the direct supervision of a Doctor General Practitioner registered in good standing with the College of Physicians and Surgeons of Ontario (CPSO).
3. The estimated totals provided herein are approximate and may vary based on the clinical findings during your consultation, additional diagnostic requirements identified by the Doctor General Practitioner, or changes in your treatment plan.
4. Cancellation policy: Appointments cancelled with less than 24 hours' notice may be subject to a no-show fee of $50.00 CAD, as per the practice's standard policy in Toronto, Ontario.
5. Payment is due at the time of service unless a different arrangement has been made in writing. Accepted payment methods include Interac e-Transfer, debit, credit (Visa, Mastercard, Amex), and certified cheque.
6. This Quotation Estimate does not guarantee specific medical outcomes. The Doctor General Practitioner reserves the right to modify the treatment plan based on clinical judgment and the patient's evolving health needs.
7. All patient information is handled in strict compliance with the Personal Health Information Protection Act (PHIPA) of Ontario and the federal Privacy Act of Canada.
8. This document is a Quotation Estimate only and does not constitute a binding contract for services. A formal treatment agreement will be executed upon the patient's acceptance of this estimate.
Acceptance & AuthorizationBy signing below, the patient (or authorized guardian) acknowledges receipt of this Quotation Estimate, confirms understanding of the estimated costs associated with Doctor General Practitioner services in Canada Toronto, and authorizes the practice to proceed with the outlined course of care. The patient further consents to the sharing of relevant medical information with the patient's insurance provider for billing purposes.
Patient / Authorized Guardian SignatureName: ______________________________
Date: ______________________________ Doctor General Practitioner – Authorizing Physician
Dr. Margaret Chen, MD, FRCPC
CPSO License No. 4829173
Date: ______________________________ ⬇️ Download as DOCX Edit online as DOCX
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