Quotation Estimate Doctor General Practitioner in Israel Tel Aviv –Free Word Template Download with AI
Doctor General Practitioner Services — Israel Tel Aviv
Document No. QTE-TLV-2025-0487
Provider (Quoting Party)
Dr. Miriam Levi, MD
Doctor General Practitioner
Levi Family Medicine Clinic
142 Dizengoff Street, Floor 3
Tel Aviv-Yafo, 6777512, Israel
Tel: +972-3-621-4478
Email: [email protected]
License No. 1234567 — Israeli Medical Licensing Authority
Client (Receiving Party)
Mr. David Cohen
Private Individual
88 Rothschild Boulevard, Apt. 12B
Tel Aviv-Yafo, 6777512, Israel
Tel: +972-52-774-3321
Email: [email protected]
Health Insurance: Clalit Health Fund
Member ID: 004-556-789
Quotation Details
Date of Issue: 15 June 2025
Valid Until: 15 July 2025 (30 days)
Currency: Israeli New Shekel (ILS / NIS)
Service Location: Tel Aviv, Israel
Reference
Subject: Comprehensive Annual Health Assessment & Preventive Care Package
Referral: Self-referred
Priority: Standard
The following Quotation Estimate outlines the full range of medical services to be provided by Dr. Miriam Levi, a licensed Doctor General Practitioner operating in Tel Aviv, Israel. This estimate covers a comprehensive annual wellness program designed to maintain optimal health, detect early-stage conditions, and provide ongoing primary care management in accordance with the standards set by the Israeli Ministry of Health and the Israeli Medical Association.
| # | Service Description | Quantity | Unit Price (ILS) | Subtotal (ILS) |
|---|---|---|---|---|
| 1 | Initial Consultation with Doctor General Practitioner — Full medical history review, physical examination, and personalized health plan formulation (Tel Aviv clinic, 60 minutes) | 1 session | 450.00 | 450.00 |
| 2 | Comprehensive Blood Panel — Complete Blood Count (CBC), lipid profile, fasting glucose, HbA1c, liver function tests, renal panel, thyroid function (TSH, T3, T4), and vitamin D levels | 1 panel | 820.00 | 820.00 |
| 3 | Cardiovascular Screening — Resting electrocardiogram (ECG), blood pressure monitoring, and cardiovascular risk assessment by the Doctor General Practitioner | 1 session | 380.00 | 380.00 |
| 4 | Abdominal & Pelvic Ultrasound — Diagnostic imaging performed at a certified Tel Aviv medical imaging center, with results reviewed by the Doctor General Practitioner | 1 scan | 650.00 | 650.00 |
| 5 | Follow-Up Consultation (Month 3) — Review of lab results, medication adjustments, lifestyle counseling, and preventive care planning | 1 session | 350.00 | 350.00 |
| 6 | Follow-Up Consultation (Month 6) — Mid-year health check, repeat targeted blood work, and progress evaluation by the Doctor General Practitioner | 1 session | 350.00 | 350.00 |
| 7 | Follow-Up Consultation (Month 12) — Annual review, updated health plan, and coordination with any specialist referrals within the Tel Aviv medical network | 1 session | 350.00 | 350.00 |
| 8 | Preventive Vaccinations — Annual influenza vaccine and any additional immunizations recommended by the Doctor General Practitioner per Israeli Ministry of Health guidelines | 2 doses | 120.00 | 240.00 |
| 9 | Health Records Management & Digital Portal Access — Secure electronic medical record storage, appointment scheduling, and telemedicine access for the full 12-month period in Tel Aviv | 12 months | 180.00 | 180.00 |
| 10 | Urgent Same-Day Appointment (Included) — One complimentary urgent visit with the Doctor General Practitioner for acute symptoms arising during the coverage period | 1 visit | 0.00 | 0.00 |
| Subtotal | 3,770.00 ILS |
| VAT (18% — Israel) | 678.60 ILS |
| Insurance Reimbursement (Clalit — estimated) | -1,200.00 ILS |
| Net Amount Due by Client | 3,248.60 ILS |
Terms & Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, pricing may be subject to revision based on current Israeli medical service fee schedules.
- All services will be rendered at the Levi Family Medicine Clinic located in Tel Aviv, Israel, or at pre-approved partner facilities within the Tel Aviv metropolitan area. The Doctor General Practitioner reserves the right to refer the client to a specialist if clinically indicated, and such referral fees are not included in this estimate.
- Payment is due within fourteen (14) days of the client's written acceptance of this Quotation Estimate. Payment may be made via bank transfer to the clinic's Israeli bank account, credit card, or through the Clalit Health Fund reimbursement process where applicable.
- The estimated insurance reimbursement amount is based on current Clalit Health Fund coverage policies as of the date of this Quotation Estimate. Actual reimbursement amounts are subject to the terms of the client's specific insurance plan and may vary.
- Cancellation of scheduled appointments must be made at least 48 hours in advance. Late cancellations or no-shows will be charged at 50% of the applicable session fee as per standard practice in Tel Aviv medical clinics.
- All medical records, test results, and health data collected during the engagement are protected under the Israeli Privacy Protection Law, 5741-1981, and the Israeli Medical Information Protection regulations. The Doctor General Practitioner and clinic staff are bound by strict confidentiality obligations.
- This Quotation Estimate does not constitute a guarantee of specific medical outcomes. The Doctor General Practitioner will exercise professional medical judgment in determining the most appropriate course of care for the client's individual health needs.
- Any additional services, laboratory tests, imaging studies, or specialist consultations not explicitly listed in this document will be quoted separately and require the client's prior written consent before being performed.
- This Quotation Estimate is governed by the laws of the State of Israel. Any disputes arising from this agreement shall be subject to the exclusive jurisdiction of the competent courts in Tel Aviv, Israel.
Authorized by (Provider):
Dr. Miriam Levi, MDDoctor General Practitioner
Levi Family Medicine Clinic, Tel Aviv
Accepted by (Client):
Mr. David CohenSignature & Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
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