Quotation Estimate Ophthalmologist in Bangladesh Dhaka –Free Word Template Download with AI
Comprehensive Ophthalmologist Services — Bangladesh Dhaka
Provider / Ophthalmologist Clinic
Dhaka Vision Care & Ophthalmology Centre
House 42, Road 11, Banani, Dhaka-1213, Bangladesh
Phone: +880-2-9887654 | +880-1711-234567
Email: [email protected]
License No.: BMA/DHA/OPH/2024/0087
Prepared For (Client)
Mr./Ms. [Client Full Name]
[Client Address], Dhaka, Bangladesh
Phone: +880-1XXXXXXXXX
Email: [email protected]
Patient ID: DVC-2025-04521
This Quotation Estimate outlines the full scope of ophthalmological services to be provided by our qualified Ophthalmologist team at our facility in Bangladesh Dhaka. All procedures, consultations, and diagnostic tests listed below have been recommended following the initial assessment of the patient's ocular health. Prices are inclusive of standard materials but exclude any unforeseen complications that may require additional intervention.
| # | Service / Procedure Description | Ophthalmologist / Specialist | Qty | Unit Price (BDT) | Subtotal (BDT) |
|---|---|---|---|---|---|
| 1 | Comprehensive Eye Examination & Consultation (including visual acuity, refraction, intraocular pressure, and fundus examination) | Dr. A. Rahman, Consultant Ophthalmologist | 1 | 2,500 | 2,500 |
| 2 | Optical Coherence Tomography (OCT) of the Retina & Macula | Diagnostic Imaging Unit | 2 | 3,200 | 6,400 |
| 3 | Slit-Lamp Biomicroscopy & Anterior Segment Assessment | Dr. A. Rahman, Consultant Ophthalmologist | 1 | 1,800 | 1,800 |
| 4 | Cataract Surgery (Phacoemulsification with Intraocular Lens Implantation) — Right Eye | Dr. S. Karim, Senior Ophthalmologist & Cataract Surgeon | 1 | 45,000 | 45,000 |
| 5 | Cataract Surgery (Phacoemulsification with Intraocular Lens Implantation) — Left Eye | Dr. S. Karim, Senior Ophthalmologist & Cataract Surgeon | 1 | 45,000 | 45,000 |
| 6 | Post-Operative Follow-Up Visits (4 sessions over 6 weeks) | Dr. A. Rahman, Consultant Ophthalmologist | 4 | 1,200 | 4,800 |
| 7 | Prescription of Post-Operative Eye Drops (Antibiotic, Anti-inflammatory, Lubricant) — 30-day supply | Pharmacy, Dhaka Vision Care | 1 | 3,500 | 3,500 |
| 8 | Prescription Spectacle Lenses (Single Vision, Anti-Reflective Coating) & Frame | Optical Department | 1 | 8,500 | 8,500 |
| 9 | Visual Field Test (Perimetry) — Baseline & Post-Operative | Diagnostic Imaging Unit | 2 | 2,000 | 4,000 |
| 10 | Emergency Ophthalmologist On-Call Access (24/7, 3-month validity) | On-Call Ophthalmologist Team | 1 | 5,000 | 5,000 |
| GRAND TOTAL (BDT) | 126,500 | ||||
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After the expiry date, prices may be revised due to changes in pharmaceutical costs, equipment maintenance, or regulatory adjustments within Bangladesh Dhaka.
- All ophthalmological procedures listed in this estimate will be performed by a licensed and board-certified Ophthalmologist registered with the Bangladesh Medical and Dental Council (BMDC). The patient is entitled to request the specific Ophthalmologist named in this document.
- A 50% advance payment (BDT 63,250) is required to confirm the surgical schedule. The remaining balance (BDT 63,250) is due within seven (7) days following the completion of the final post-operative follow-up visit.
- Payment may be made via bank transfer to the clinic's designated account in Dhaka, Bangladesh, or by cash/cheque at the front desk. A receipt will be issued for every transaction.
- This Quotation Estimate does not cover complications arising from pre-existing conditions not disclosed during the initial consultation, nor does it include hospitalization beyond the standard day-care surgical protocol unless medically necessary. Any additional inpatient stay will be billed separately at BDT 8,000 per night.
- The Ophthalmologist reserves the right to modify the surgical plan intra-operatively if unforeseen anatomical or pathological findings necessitate a change in technique. Any such modifications will be communicated to the patient's guardian or authorized representative prior to the procedure where feasible.
- All diagnostic imaging (OCT, Perimetry) reports will be provided in both printed and digital (PDF) format. The patient may request a certified copy for referral to any other Ophthalmologist or specialist within Bangladesh Dhaka or internationally.
- This Quotation Estimate is subject to the medical ethics and patient care standards set forth by the Bangladesh Medical Association and the Department of Health, Government of Bangladesh.
- In the event of cancellation by the patient after the advance payment has been made, a 20% administrative fee will be deducted from the refund. Cancellations within 48 hours of the scheduled surgery will forfeit the full advance payment.
- Confidentiality: All patient records, diagnostic images, and treatment details are protected under the Bangladesh Digital Security Act and the clinic's internal data privacy policy. No information will be shared without written consent.
Prepared By:
Dr. A. Rahman, MD (Ophthalmology)Consultant Ophthalmologist
Dhaka Vision Care & Ophthalmology Centre
Signature & Seal
Accepted By (Patient / Guardian):
Name: ___________________________Date: ___________________________
Signature: ___________________________
Phone: ___________________________
© 2025 Dhaka Vision Care & Ophthalmology Centre, Bangladesh Dhaka. All rights reserved. | Quotation Estimate No. DVC-QE-2025-0783 | Page 1 of 1
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