Quotation Estimate Ophthalmologist in Colombia Bogotá –Free Word Template Download with AI
Clínica Ocular Andina – Ophthalmologist Center
Carrera 11 # 93A-45, Piso 4, Zona Rosa, Bogotá D.C., Colombia
Tel: +57 (601) 555 7842 | Email: [email protected]
NIT: 901.234.567-8 | Registro Sanitario: 2019-04567-12
| Client Name: | Señor(a) [Full Name to be completed] |
| Identification (Cédula): | [C.C. Number] |
| Address: | [Street, Neighborhood, Bogotá D.C., Colombia] |
| Contact Phone: | [+57 Phone Number] |
| Email: | [Email Address] |
| Health Insurance (EPS): | [EPS Name – e.g., Sanitas, Sura, Nueva EPS, etc.] |
This Quotation Estimate has been prepared by Clínica Ocular Andina, a specialized Ophthalmologist practice located in the heart of Colombia Bogotá, to provide the client with a comprehensive and transparent breakdown of all anticipated costs associated with ophthalmological evaluation, diagnostic procedures, and potential therapeutic interventions. This document serves as a formal Quotation Estimate and does not constitute a binding contract until both parties have reviewed, agreed upon, and signed the acceptance section at the end of this document. All services described herein will be performed by a board-certified Ophthalmologist or a team of Ophthalmologist specialists at our facility in Colombia Bogotá, in strict compliance with the regulations established by the Ministry of Health and Social Welfare of Colombia (Ministerio de Salud y Protección Social) and the Colombian Ophthalmology Society (Sociedad Colombiana de Oftalmología).
The following Quotation Estimate encompasses a full ophthalmological workup and treatment plan. Our Ophthalmologist team in Colombia Bogotá will conduct the following procedures as part of this engagement:
| Item No. | Description of Ophthalmologist Service | Quantity | Unit Price (COP) | Subtotal (COP) |
|---|---|---|---|---|
| 01 | Initial comprehensive consultation with a senior Ophthalmologist (includes medical history review, visual acuity test, and preliminary assessment) | 1 | 380.000 | 380.000 |
| 02 | Dilated fundus examination and retinal imaging (OCT – Optical Coherence Tomography) performed by the Ophthalmologist | 1 | 295.000 | 295.000 |
| 03 | Anterior segment evaluation including slit-lamp biomicroscopy, intraocular pressure measurement (tonometry), and corneal topography | 1 | 220.000 | 220.000 |
| 04 | Visual field perimetry (Humphrey 30-2) to assess peripheral vision, administered under Ophthalmologist supervision | 1 | 185.000 | 185.000 |
| 05 | Prescription of corrective lenses (spectacles) – standard single-vision, including lens grinding and frame fitting | 1 | 450.000 | 450.000 |
| 06 | Follow-up consultation with the Ophthalmologist (30 days post-initial visit) for treatment plan review and adjustment | 1 | 250.000 | 250.000 |
| 07 | Pharmacological treatment – topical ophthalmic medications (antibiotic/anti-inflammatory drops, 30-day supply) | 1 | 120.000 | 120.000 |
| 08 | Administrative fee for medical records, digital imaging storage, and certified Ophthalmologist report for EPS or employer | 1 | 85.000 | 85.000 |
| TOTAL ESTIMATED COST (COP): | 1.985.000 | |||
| TOTAL ESTIMATED COST (USD – approx. at 4.100 COP/USD): | USD 484.15 | |||
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, prices may be subject to revision due to changes in pharmaceutical costs, equipment maintenance, or regulatory adjustments in Colombia Bogotá.
- Payment Method: Payment may be made in full upon acceptance of this Quotation Estimate, or in two (2) equal installments: 50% upon signing and 50% at the follow-up consultation. Accepted methods include cash, debit/credit card (Visa, Mastercard, American Express), and bank transfer to our account at Banco de Bogotá.
- Insurance Coverage: If the client holds active health insurance (EPS) in Colombia, the Ophthalmologist services may be partially or fully covered under the Plan de Beneficios en Salud (PBS). The client is responsible for any co-payment (copago) or services not included in the PBS. Our office in Colombia Bogotá will assist with prior authorization requests to the EPS.
- Scheduling: Appointments with the Ophthalmologist will be scheduled within five (5) business days of confirmed payment. The client will receive a confirmation via SMS and email. Rescheduling must be done at least 24 hours in advance.
- Confidentiality: All medical information, diagnostic images, and treatment records are handled in accordance with Colombian Law 1581 of 2012 (Data Protection Law) and the regulations of the Superintendencia de Industria y Comercio. The Ophthalmologist and all staff members are bound by strict professional confidentiality.
- Warranty: Corrective lenses include a 90-day warranty against manufacturing defects. Surgical procedures, if applicable and not included in this Quotation Estimate, will be subject to a separate detailed estimate.
- Exclusions: This Quotation Estimate does not include emergency ophthalmological care, surgical interventions (cataract extraction, LASIK, retinal surgery), or specialist referrals (neuro-ophthalmology, pediatric ophthalmology) unless explicitly added in writing.
- Regulatory Compliance: All Ophthalmologist services are performed in compliance with the Colombian Health Regulatory Authority (CRES) resolutions and the standards set by the Juntas de Calificación de Profesionales de la Salud in Colombia Bogotá.
By signing below, the client acknowledges having received and reviewed this Quotation Estimate for Ophthalmologist services at Clínica Ocular Andina in Colombia Bogotá. The client agrees to the terms, conditions, and pricing outlined in this document and authorizes the Ophthalmologist team to proceed with the described services upon confirmation of payment.
Client SignatureName: _________________________
C.C.: _________________________
Date: _________________________ Ophthalmologist / Clinic Representative
Dr. [Name], Ophthalmologist
R.M.: 12345678
Date: _________________________ ⬇️ Download as DOCX Edit online as DOCX
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