Quotation Estimate Ophthalmologist in Brazil Rio de Janeiro –Free Word Template Download with AI

This Quotation Estimate is issued by Clinica Ocular Rio de Janeiro to provide a comprehensive, itemized breakdown of all anticipated costs associated with the full ophthalmological care plan recommended for the client listed above. As a licensed Ophthalmologist practice operating in Brazil, Rio de Janeiro, our clinic adheres to all regulatory standards set forth by the Conselho Regional de Medicina do Estado do Rio de Janeiro (CREMERJ) and the Brazilian Federal Health Ministry (Ministério da Saúde). This Quotation Estimate covers a complete diagnostic and therapeutic ophthalmology program, including initial consultation, advanced imaging, surgical intervention if indicated, and post-operative follow-up care.

The following services have been recommended by our senior Ophthalmologist, Dr. Helena Vasconcelos (CRM-RJ 38.912), following a preliminary screening examination conducted on 10 June 2025 at our facility in Rio de Janeiro, Brazil. The Ophthalmologist has identified bilateral cataract formation (grade II) with early-stage age-related macular degeneration in the left eye. The treatment plan outlined in this Quotation Estimate is designed to restore optimal visual acuity and prevent further deterioration.

This Quotation Estimate may be settled through the following options, all processed in Brazilian Reais (BRL) at our facility in Rio de Janeiro, Brazil:

• Full Prepayment: 5% discount applied (as reflected above). Payment due 7 business days prior to the first surgical date. Acceptable via bank transfer (TED/PIX) or credit card (up to 12 installments).
• Installment Plan: 40% upon signing this Quotation Estimate, 40% on the day of the first surgery, and 20% at the 3-month post-operative visit. No interest applied for up to 3 installments.
• Health Insurance (Convênio): We accept Unimed, Bradesco Saúde, SulAmérica, and Amil. The Ophthalmologist will submit pre-authorization requests to the insurer. The client is responsible for any co-pay or deductible amounts not covered by the plan.

• This Quotation Estimate is valid for 30 calendar days from the date of issue. Prices are subject to revision after the validity period expires.
• All Ophthalmologist services are performed in compliance with the Brazilian General Data Protection Law (LGPD — Lei 13.709/2018). Patient records are stored securely in Rio de Janeiro, Brazil.
• Surgical procedures are conducted in a facility accredited by the ANVISA (Agência Nacional de Vigilância Sanitária) and the CREMERJ.
• The Ophthalmologist reserves the right to modify the surgical plan intraoperatively if unforeseen anatomical conditions are discovered. Any additional costs arising from such modifications will be communicated to the client or their designated representative prior to proceeding, and a supplementary Quotation Estimate will be issued.
• Cancellation of scheduled surgery by the client more than 72 hours in advance incurs no penalty. Cancellations within 72 hours are subject to a 15% administrative fee on the surgical component of this Quotation Estimate.
• This Quotation Estimate does not constitute a guarantee of specific visual outcomes. The Ophthalmologist will discuss all risks, benefits, and alternatives during the pre-operative consultation.
• All prices are inclusive of ICMS (Imposto sobre Circulação de Mercadorias e Serviços) applicable in the state of Rio de Janeiro, Brazil.

By signing below, the client acknowledges receipt of this Quotation Estimate, confirms understanding of the recommended Ophthalmologist treatment plan, and authorizes Clinica Ocular Rio de Janeiro to proceed with the services described herein under the payment terms selected.