Quotation Estimate Ophthalmologist in Canada Vancouver –Free Word Template Download with AI
Pacific Coast Vision & Ophthalmology Centre
1280 West Georgia Street, Suite 450, Vancouver, British Columbia, Canada V6E 1Y2
Phone: (604) 555-0198 | Email: [email protected]
Health Registry No.: BC-OPH-2024-00871
| Quotation Estimate No.: | QEST-2025-04172 | Date of Issue: | June 12, 2025 |
| Valid Until: | July 12, 2025 (30 days) | Currency: | Canadian Dollars (CAD) |
| Prepared For: | Mr. Jonathan R. MacLeod | Patient File No.: | PF-2025-33841 |
| Address: | 4721 Oakridge Avenue, Vancouver, BC, Canada V6M 2K4 | Referring Physician: | Dr. Sarah Chen, Family Medicine |
| Insurance Provider: | Blue Cross BC (Policy #BCX-9928471) | Ophthalmologist: | Dr. Alan P. Whitfield, MD, FRCSC |
This Quotation Estimate has been prepared by our licensed Ophthalmologist, Dr. Alan P. Whitfield, FRCSC, to outline the anticipated costs for a full diagnostic and therapeutic ophthalmology program. All services described herein will be delivered at our clinic located in Canada Vancouver, in full compliance with the British Columbia Medical Services Plan (MSP) guidelines and the College of Physicians and Surgeons of British Columbia (CPSBC) regulatory standards. This Quotation Estimate is provided to assist the patient and their insurance provider in understanding the financial scope of the recommended ophthalmological care.
ITEMIZED SERVICES AND ESTIMATED COSTS| # | Service Description | Ophthalmologist Fee Code | Qty | Unit Price (CAD) | Estimated Total (CAD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation & Initial Eye Examination (including visual acuity testing, refraction, and slit-lamp biomicroscopy) | OPH-101 | 1 | $285.00 | $285.00 |
| 2 | Dilated Fundus Examination with Optical Coherence Tomography (OCT) of the macula and optic nerve head | OPH-204 | 1 | $195.00 | $195.00 |
| 3 | Automated Perimetry (Humphrey Visual Field Testing) – Standard 24-2 protocol, both eyes | OPH-310 | 2 | $145.00 | $290.00 |
| 4 | Anterior Segment & Posterior Segment Ultrasound (B-Scan) for assessment of intraocular structures | OPH-415 | 1 | $175.00 | $175.00 |
| 5 | Corneal Topography and Pachymetry (measuring corneal curvature and thickness) | OPH-520 | 1 | $120.00 | $120.00 |
| 6 | Fluorescein Fundus Photography (6-field series, both eyes) for documentation and longitudinal monitoring | OPH-630 | 1 | $160.00 | $160.00 |
| 7 | Therapeutic Intravitreal Injection (Anti-VEGF) – Estimated for up to 3 sessions over a 12-week period | OPH-745 | 3 | $1,250.00 | $3,750.00 |
| 8 | Follow-up Ophthalmologist Review Appointments (post-injection monitoring, 4-week intervals) | OPH-810 | 3 | $150.00 | $450.00 |
| 9 | Prescription of Custom Spectacle Lenses (progressive, anti-reflective coating) – dispensed by our in-house optician in Canada Vancouver | OPH-920 | 1 | $420.00 | $420.00 |
| 10 | Annual Comprehensive Ophthalmologist Follow-Up (next 12 months) – includes repeat OCT, visual field, and dilated exam | OPH-1001 | 1 | $380.00 | $380.00 |
| SUBTOTAL (All Ophthalmologist Services) | $6,425.00 | ||||
| Estimated MSP / Insurance Coverage (approx. 70%) | ($4,497.50) | ||||
| ESTIMATED PATIENT RESPONSIBILITY (Out-of-Pocket) | $1,927.50 | ||||
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, the Ophthalmologist fees and associated costs may be subject to revision in accordance with the current British Columbia fee schedule.
- All Ophthalmologist services listed in this Quotation Estimate will be performed by Dr. Alan P. Whitfield or a credentialed associate Ophthalmologist at the Pacific Coast Vision & Ophthalmology Centre in Canada Vancouver. The patient will be notified in advance if a different Ophthalmologist is scheduled to perform any procedure.
- Insurance coverage amounts are estimates based on the patient's current Blue Cross BC policy. The final reimbursement amount is determined solely by the insurance provider. The patient is responsible for any difference between the estimated coverage and the actual benefit paid.
- Payment for the patient's out-of-pocket portion is due within fourteen (14) days of the final invoice. Our office in Canada Vancouver accepts Visa, Mastercard, Interac e-Transfer, and direct bank transfer. A 1.5% monthly late fee will apply to overdue balances.
- This Quotation Estimate does not constitute a guarantee of medical outcomes. The Ophthalmologist reserves the right to modify the treatment plan based on clinical findings during the examination. Any additional procedures not listed herein will require a revised Quotation Estimate and written patient consent prior to execution.
- All medical records, imaging data, and diagnostic reports generated during the course of this Ophthalmologist care plan will be stored in compliance with the Personal Information Protection Act (PIPA) of British Columbia and the federal Privacy Act of Canada.
- Cancellations or rescheduling of Ophthalmologist appointments must be made at least 48 hours in advance. Late cancellations may incur a fee of $75.00 as outlined in our Canada Vancouver clinic policies.
- This Quotation Estimate is prepared for the exclusive use of the named patient and their authorized insurance representative. It may not be transferred or applied to any other individual without written authorization from the Ophthalmologist.
By signing below, the patient acknowledges receipt of this Quotation Estimate for Ophthalmologist services in Canada Vancouver and agrees to the terms and conditions outlined above. The patient confirms that they have had the opportunity to ask questions regarding the estimated costs, the scope of the Ophthalmologist's recommended treatment, and their insurance coverage.
Patient Signature & Date Ophthalmologist – Dr. Alan P. Whitfield, MD, FRCSC & Date ⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
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