Quotation Estimate Ophthalmologist in Chile Santiago –Free Word Template Download with AI

Quotation Estimate No.: QE-2025-0847 Date of Issue: June 15, 2025 Valid Until: July 15, 2025 Location: Chile Santiago

Client Name: Don Carlos Mendoza Rojas	RUT: 12.345.678-9
Address: Calle Los Aromos 456, Depto. 3B, Las Condes, Chile Santiago	Phone: +56 9 8765 4321
Email: [email protected]	Insurance: Isapre Cruz Blanca, Plan Premium

This Quotation Estimate is issued by Clínica Ocular Andina, a specialized ophthalmology center located in the heart of Chile Santiago, to provide a comprehensive breakdown of the professional services to be rendered by our board-certified Ophthalmologist, Dr. Valentina Fuentes Soto (Matrícula Médica: 145.678). The following services encompass a full diagnostic and therapeutic ophthalmological evaluation tailored to the client's specific visual health needs. All procedures will be performed in accordance with the standards established by the Colegio Médico de Chile and the regulations of the Ministerio de Salud de Chile.

Item	Description	Qty	Unit Price (CLP)	Subtotal (CLP)
1	Comprehensive Ophthalmologist Consultation – Initial evaluation including medical history review, visual acuity testing, and slit-lamp examination	1	$45,000	$45,000
2	Dilated Fundus Examination – Pupil dilation drops and detailed retinal and optic nerve assessment by the Ophthalmologist	1	$28,000	$28,000
3	Optical Coherence Tomography (OCT) – High-resolution cross-sectional imaging of the retina and macula	1	$52,000	$52,000
4	Automated Perimetry (Visual Field Test) – 24-2 and 30-2 protocols to evaluate peripheral vision	1	$38,000	$38,000
5	Anterior Segment Biometry – Measurement of axial length, corneal curvature, and anterior chamber depth for refractive planning	1	$35,000	$35,000
6	Intraocular Pressure Measurement (Tonometry) – Non-contact and Goldmann applanation tonometry	1	$18,000	$18,000
7	Corneal Topography – 3D mapping of the anterior corneal surface for astigmatism assessment	1	$42,000	$42,000
8	Follow-up Ophthalmologist Consultation – Post-evaluation review of results, treatment plan discussion, and prescription of corrective lenses or medication	1	$35,000	$35,000
9	Pharmacological Supplies – Mydriatic drops, anesthetic eye drops, and post-procedure lubricating ointment	1	$12,000	$12,000
10	Medical Report and Documentation – Detailed written report in Spanish and English, including all imaging results, suitable for insurance or international medical records	1	$20,000	$20,000
TOTAL ESTIMATED COST (CLP)				$325,000
TOTAL ESTIMATED COST (USD – approx. at 950 CLP/USD)				$342.11

This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, prices may be subject to revision based on current market conditions in Chile Santiago.
All services will be performed by a licensed Ophthalmologist or under the direct supervision of one. The attending physician for this engagement is Dr. Valentina Fuentes Soto, with over fifteen years of clinical experience in ophthalmology in Chile Santiago.
The total cost of $325,000 CLP includes all diagnostic procedures, professional fees, and consumable materials listed above. It does not include surgical interventions, which would require a separate and detailed Quotation Estimate.
Payment is due within fifteen (15) business days of the date of this Quotation Estimate. Accepted payment methods include bank transfer (transferencia bancaria), credit card (Visa, Mastercard, American Express), and cash at our Chile Santiago clinic office.
Should the client hold active Isapre or Fonasa coverage, our administrative team in Chile Santiago will process the corresponding pre-authorization and billing directly with the insurance provider. The client is responsible for any copayments or deductibles not covered by their plan.
All medical records, imaging files, and reports generated during the ophthalmological evaluation will be stored in compliance with Chilean data protection law (Ley 19.628) and the patient's right to privacy.
This Quotation Estimate does not constitute a binding contract until formally accepted in writing by both parties. Acceptance may be communicated via email to [email protected] or by signing the acknowledgment section below.
Any additional procedures identified during the initial Ophthalmologist consultation that were not included in this estimate will be communicated to the client prior to execution, with a supplementary Quotation Estimate provided for approval.

The full ophthalmological evaluation is scheduled to take approximately two and a half (2.5) hours and will be conducted at our clinic located at Av. Providencia 1234, Of. 501, Providencia, Chile Santiago. The client is advised to arrive thirty minutes prior to the appointment time. Due to the administration of mydriatic (pupil-dilating) drops, the client should not drive for a minimum of four hours following the dilated fundus examination. Sunglasses and a companion for the return journey are strongly recommended. The follow-up Ophthalmologist consultation will be scheduled within seven to ten business days of the initial evaluation, at a time convenient for the client.

By signing below, both parties acknowledge and accept the terms, scope, and pricing outlined in this Quotation Estimate for Ophthalmologist services in Chile Santiago.

For Clínica Ocular Andina
Dr. Valentina Fuentes Soto
Ophthalmologist – Lead Physician
Matrícula Médica: 145.678
Date: ___________________ Client Acknowledgment
Don Carlos Mendoza Rojas
RUT: 12.345.678-9
Signature: ___________________
Date: ___________________ ⬇️ Download as DOCX Edit online as DOCX

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