Quotation Estimate Ophthalmologist in Canada Toronto –Free Word Template Download with AI
Toronto Vision & Eye Care Centre
2875 Bloor Street West, Suite 410, Toronto, Ontario, Canada M8X 2Y1
Phone: (416) 555-0192 | Email: [email protected]
College of Physicians and Surgeons of Ontario (CPSO) Licensed Practice
Client Information
| Patient Name: | Mr. James A. Richardson |
| Address: | 1420 Avenue Road, Toronto, Ontario, Canada M5M 4A8 |
| Insurance Provider: | Sun Life Financial (Plan #SL-884210) |
| Referring Physician: | Dr. Alan Whitfield, Family Medicine, North York |
Scope of Services – Ophthalmologist Consultation and Treatment Plan
This Quotation Estimate has been prepared by our board-certified Ophthalmologist at the Toronto Vision & Eye Care Centre, located in the heart of Canada Toronto, to provide a comprehensive financial overview of the recommended ophthalmic services. The following estimate covers a full diagnostic workup, surgical intervention, and post-operative follow-up care as discussed during the initial consultation on June 5, 2025. All services will be performed in accordance with the standards set by the College of Physicians and Surgeons of Ontario and the Canadian Ophthalmological Society.
Itemized Cost Breakdown
| # | Service Description | Fee Code | Quantity | Amount (CAD) |
|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Initial Consultation and History Review | K001 | 1 | $285.00 |
| 2 | Dilated Fundus Examination with Optical Coherence Tomography (OCT) | K012 | 1 | $195.00 |
| 3 | Anterior Segment Biometry and Corneal Topography Mapping | K018 | 1 | $165.00 |
| 4 | Visual Field Testing (Humphrey 24-2 and 10-2) | K022 | 2 | $240.00 |
| 5 | Phacoemulsification Cataract Surgery with Premium Toric IOL (Right Eye) | K045 | 1 | $4,850.00 |
| 6 | Phacoemulsification Cataract Surgery with Premium Toric IOL (Left Eye) | K045 | 1 | $4,850.00 |
| 7 | Pre-operative Anaesthesia Assessment and Medication Clearance | K030 | 1 | $120.00 |
| 8 | Post-operative Follow-up Visits (Week 1, Week 4, Month 3, Month 6) | K050 | 4 | $480.00 |
| 9 | Prescription Post-operative Eye Drops and Medications (4-week supply) | K060 | 1 | $185.00 |
| 10 | Emergency Post-operative Visit (if required within 30 days) | K065 | 1 | $220.00 |
| Subtotal | $11,590.00 | |||
| HST (13% – Ontario, Canada) | $1,506.70 | |||
| Grand Total (CAD) | $13,096.70 | |||
Terms and Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, fees may be adjusted to reflect changes in supply costs, surgical consumables, or provincial fee schedules in Ontario, Canada.
- All ophthalmic procedures will be performed by Dr. Margaret Chen, a fellowship-trained Ophthalmologist with over fifteen years of surgical experience in the Toronto, Canada region, or by a designated associate surgeon of equivalent qualification.
- Surgical procedures will take place at the Toronto Eye Surgery Centre, a fully accredited facility located in downtown Canada Toronto, in compliance with all Health Canada and Ontario Ministry of Health and Long-Term Care regulations.
- A deposit of 20% of the total estimated amount ($2,619.34 CAD) is required to confirm the surgical booking. The remaining balance is due within fourteen (14) days following the completion of all post-operative visits.
- Payment may be made via Interac e-Transfer, credit card (Visa, Mastercard, Amex), or certified cheque. Installment payment plans are available upon request for patients residing in the Greater Toronto Area.
- This estimate does not include costs for additional procedures that may become necessary if intra-operative findings differ from pre-operative expectations. Any such additional services will be discussed with the patient or their authorized representative prior to proceeding, and a revised Quotation Estimate will be issued.
- All medical records, surgical reports, and correspondence will be maintained in accordance with Ontario's Personal Health Information Protection Act (PHIPA) and the federal Privacy Act of Canada.
- The patient acknowledges that this Quotation Estimate is a good-faith financial projection and not a guarantee of final billing. Actual charges may vary slightly based on the specific surgical technique employed, the number of premium lens options selected, and any ancillary services required.
- By signing below, the patient confirms that they have received, read, and understood this Quotation Estimate for Ophthalmologist services in Canada Toronto, and that they consent to proceed with the outlined treatment plan subject to the terms stated herein.
Dr. Margaret Chen, MD, FRCSC
Toronto Vision & Eye Care Centre
Signature: _________________________
Date: _________________________ Patient / Authorized Representative
Mr. James A. Richardson
Signature: _________________________
Date: _________________________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT