Quotation Estimate Ophthalmologist in Australia Brisbane –Free Word Template Download with AI
Professional Ophthalmologist Services — Australia Brisbane
Provider Details
Brisbane Vision & Eye Care Centre
42 George Street, Level 3
Brisbane, Queensland 4000
Australia
Phone: +61 7 3210 4567
Email: [email protected]
ABN: 54 123 456 789
Client Details
Mr. James R. Thompson
187 Anzac Parade
South Brisbane, Queensland 4101
Australia
Phone: +61 4 1234 5678
Email: [email protected]
Medicare Number: 1234 5678 901
This Quotation Estimate has been prepared by our qualified Ophthalmologist team at Brisbane Vision & Eye Care Centre, Australia Brisbane, to outline the comprehensive range of diagnostic, therapeutic, and surgical ophthalmology services recommended for the client following a full clinical assessment conducted on 10 June 2025. All pricing is quoted in Australian Dollars (AUD) and includes applicable Goods and Services Tax (GST) at the current rate of 10%.
| Ref | Description of Ophthalmologist Service | Qty | Unit Price (AUD) | Total (AUD) |
|---|---|---|---|---|
| 01 | Comprehensive Ophthalmologist Consultation & Full Dilated Eye Examination (including visual acuity testing, intraocular pressure measurement, and anterior segment assessment) | 1 | $285.00 | $285.00 |
| 02 | Dilated Fundus Examination with Optical Coherence Tomography (OCT) of the macula and optic nerve head, performed by the Ophthalmologist | 1 | $195.00 | $195.00 |
| 03 | Wide-Field Fundus Photography (300-degree) for baseline documentation and longitudinal monitoring by the Ophthalmologist | 1 | $150.00 | $150.00 |
| 04 | Anterior Segment OCT and Corneal Topography (Pentacam) to assess corneal curvature and rule out ectatic disease | 1 | $175.00 | $175.00 |
| 05 | Visual Field Testing (Humphrey 24-2 Standard Threshold) — bilateral, ordered by the Ophthalmologist | 2 | $120.00 | $240.00 |
| 06 | Phacoemulsification Cataract Surgery (right eye) with premium toric intraocular lens implant, performed by the Ophthalmologist at a Brisbane accredited surgical facility | 1 | $4,850.00 | $4,850.00 |
| 07 | Post-operative Ophthalmologist Review (Day 1, Week 1, Month 1, and Month 3 follow-up appointments in Australia Brisbane) | 4 | $110.00 | $440.00 |
| 08 | Prescription of post-operative eye drops (antibiotic, anti-inflammatory, and lubricating) dispensed through our Australia Brisbane clinic pharmacy | 1 | $85.00 | $85.00 |
| 09 | Annual Ophthalmologist Surveillance Package (12-month follow-up including OCT, visual field, and dilated exam) for ongoing monitoring in Australia Brisbane | 1 | $520.00 | $520.00 |
| Subtotal (excl. GST) | $7,940.00 |
| GST (10%) | $794.00 |
| Grand Total (incl. GST) | $8,734.00 |
| Medicare Rebate (estimated) | -$1,240.00 |
| Net Patient Liability | $7,494.00 |
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, pricing for the Ophthalmologist services listed herein may be subject to revision based on current Australian medical fee schedules and supplier costs in Australia Brisbane.
- All Ophthalmologist consultations, diagnostic imaging, and surgical procedures will be conducted at our registered facility in Australia Brisbane or at an accredited surgical centre within the Greater Brisbane metropolitan area, as specified in the itemised schedule above.
- The Ophthalmologist performing the surgical procedure is a Fellow of the Royal Australian and New Zealand College of Ophthalmologists (FRANZCO) and maintains full professional indemnity insurance in accordance with Queensland Health regulations.
- Payment for the surgical component (Item 06) is due in full prior to the scheduled procedure date. Diagnostic and consultation fees (Items 01–05) are payable at the time of the initial Ophthalmologist consultation. Post-operative review fees (Item 07) are payable at each respective appointment.
- Where applicable, Medicare Benefits Schedule (MBS) rebates and private health insurance benefits will be claimed directly by our Australia Brisbane clinic on the client's behalf. The client is responsible for any gap between the Ophthalmologist's professional fee and the applicable rebate or insurance benefit.
- This Quotation Estimate does not constitute a guarantee of surgical outcome. The Ophthalmologist will discuss all potential risks, benefits, and alternative treatments with the client during the pre-operative consultation in accordance with the Australian Medical Association's guidelines on informed consent.
- Any additional Ophthalmologist services not included in this Quotation Estimate, such as emergency post-operative reviews, additional imaging, or treatment of complications, will be quoted separately and require the client's written authorisation prior to commencement.
- All patient records, imaging data, and clinical documentation generated by the Ophthalmologist in Australia Brisbane will be stored in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles.
- This Quotation Estimate is prepared in good faith and reflects the best professional judgement of the Ophthalmologist at the time of issue. It is not a binding contract until formally accepted by the client via signature below.
By signing below, the client acknowledges that they have read and understood this Quotation Estimate for Ophthalmologist services in Australia Brisbane, and authorises the provider to proceed with the services as described. The client confirms that the Ophthalmologist has explained the recommended treatment plan, associated risks, and alternative options in full.
|
Client Signature Name: James R. Thompson Date: ______________________ |
Ophthalmologist / Authorising Practitioner Name: Dr. Sarah Mitchell, FRANZCO Date: 14 June 2025 |
Create your own Word template with our GoGPT AI prompt:
GoGPT