Quotation Estimate Ophthalmologist in Canada Montreal –Free Word Template Download with AI
Ophthalmologist Professional Services — Canada Montreal
Quotation Estimate No.: QTE-2025-MTL-04872 | Date Issued: June 12, 2025 | Valid Until: July 12, 2025
Issued By:Dr. Émilie Tremblay, MD, FRCSC
Ophthalmologist — Board-Certified
Clinique d'Ophtalmologie du Centre-Ville
1450 Rue Sainte-Catherine Ouest, Bureau 320
Canada Montreal, QC H3G 1X4
Tel: (514) 555-0198 | Email: [email protected] Prepared For:
Mr. Jonathan R. MacLeod
872 Avenue des Pins Ouest
Canada Montreal, QC H3C 2A1
Tel: (514) 555-7743
Email: [email protected]
This Quotation Estimate has been prepared by our Ophthalmologist practice in Canada Montreal to provide a comprehensive, itemized breakdown of the proposed ophthalmological care, diagnostic procedures, and surgical interventions recommended for the patient listed above. As a licensed Ophthalmologist registered with the Collège des médecins du Québec, Dr. Tremblay and her team are committed to delivering the highest standard of eye care in the Canada Montreal region. This Quotation Estimate reflects current 2025 fee schedules and is subject to the terms outlined in Section 5 of this document.
| # | Service / Procedure Description | Fee Code | Qty | Unit Price (CAD) | Subtotal (CAD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation & Initial Eye Examination (Canada Montreal clinic visit, 45 min) | OPH-101 | 1 | $285.00 | $285.00 |
| 2 | Dilated Fundus Examination with Optical Coherence Tomography (OCT) — performed by Ophthalmologist | OPH-204 | 2 | $145.00 | $290.00 |
| 3 | Anterior Segment Biomicroscopy & Intraocular Pressure Measurement (Tonometry) | OPH-210 | 2 | $95.00 | $190.00 |
| 4 | Visual Field Testing (Humphrey Perimetry) — Ophthalmologist-supervised | OPH-225 | 2 | $120.00 | $240.00 |
| 5 | Corneal Topography & Pachymetry (Canada Montreal diagnostic lab) | OPH-230 | 1 | $175.00 | $175.00 |
| 6 | Cataract Surgery (Phacoemulsification with Premium Toric IOL Implant) — Ophthalmologist-led, both eyes | OPH-501 | 2 | $4,850.00 | $9,700.00 |
| 7 | Pre-operative Surgical Assessment & Anaesthesia Consultation (Canada Montreal hospital) | OPH-510 | 1 | $320.00 | $320.00 |
| 8 | Post-operative Ophthalmologist Follow-up Visits (Week 1, Week 4, Month 3) | OPH-520 | 3 | $150.00 | $450.00 |
| 9 | Prescription Post-operative Medications (Antibiotic & Anti-inflammatory eye drops, 6-week supply) | OPH-600 | 1 | $185.00 | $185.00 |
| 10 | Custom Prescription Ophthalmic Lenses & Frame Fitting (Canada Montreal optical partner) | OPH-700 | 1 | $620.00 | $620.00 |
| Subtotal | $12,655.00 |
| Quebec Sales Tax (QST) 5% | $632.75 |
| Federal Goods & Services Tax (GST) 5% | $632.75 |
| Insurance Adjustment (RAMQ / Private Plan) | -$3,210.00 |
| Estimated Patient Responsibility | $10,710.50 |
Based on the initial diagnostic workup conducted at our Canada Montreal clinic, the Ophthalmologist has identified bilateral age-related cataracts with significant visual impairment (OD: 20/80, OS: 20/100) and early-stage myopic astigmatism. The Quotation Estimate above encompasses the full surgical and post-operative pathway. Dr. Tremblay, as the treating Ophthalmologist, recommends proceeding with bilateral phacoemulsification using premium toric intraocular lenses to address both the cataract and the residual astigmatism in a single procedure per eye. All services listed in this Quotation Estimate will be performed or supervised by the Ophthalmologist or her credentialed surgical team at the affiliated Canada Montreal surgical centre.
A deposit of 20% ($2,142.10) of the estimated patient responsibility is due upon acceptance of this Quotation Estimate to secure the Ophthalmologist's surgical schedule. The remaining balance of $8,568.40 is payable within 30 days of the final post-operative visit. Payment may be made by Interac e-Transfer, credit card (Visa, Mastercard, Amex), or certified cheque. Our Canada Montreal office accepts all major payment methods and can provide a detailed receipt for insurance reimbursement purposes.
Important Conditions Governing This Quotation Estimate
- This Quotation Estimate is valid for 30 calendar days from the date of issue. After this period, the Ophthalmologist reserves the right to revise fees based on updated Canada Montreal healthcare cost indices.
- All Ophthalmologist services are subject to the patient's medical fitness as determined by the pre-operative assessment. The Ophthalmologist may modify the surgical plan if intra-operative findings differ from pre-operative expectations, in which case a revised Quotation Estimate will be provided.
- Insurance adjustments are estimates based on the patient's current RAMQ and private plan coverage. The patient is responsible for any difference between the estimated adjustment and the actual reimbursement received from their insurer.
- This Quotation Estimate does not constitute a guarantee of surgical outcomes. The Ophthalmologist will discuss all risks, benefits, and alternatives with the patient prior to the procedure, in accordance with the standards of the Collège des médecins du Québec.
- All consultations, procedures, and follow-up visits will take place at the Ophthalmologist's clinic located in Canada Montreal unless otherwise specified. Travel or accommodation costs for out-of-area patients are not included in this Quotation Estimate.
- Confidentiality of all medical information is maintained in compliance with Quebec's Law 25 (Act respecting the protection of personal information in the digital age) and the Canadian Personal Information Protection and Electronic Documents Act (PIPEDA).
- Any cancellation of scheduled Ophthalmologist services by the patient within 72 hours of the appointment will incur a $250 administrative fee, as outlined in this Quotation Estimate.
By signing below, the patient acknowledges receipt of this Quotation Estimate, confirms understanding of the proposed Ophthalmologist services in Canada Montreal, and authorizes the Ophthalmologist to proceed with the outlined treatment plan. The patient further agrees to the payment terms and conditions set forth in this document.
Patient Signature:______________________________
Jonathan R. MacLeod
Date: _______________ Ophthalmologist / Authorized Representative:
______________________________
Dr. Émilie Tremblay, MD, FRCSC
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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