Quotation Estimate Ophthalmologist in Ethiopia Addis Ababa –Free Word Template Download with AI

Quotation Estimate No.	QA-OPH-2025-0472	Date of Issue	June 15, 2025
Valid Until	July 15, 2025 (30 days)	Currency	Ethiopian Birr (ETB) / USD
Prepared By	Dr. Alemu Tadesse, MD, FICO (Ophthalmologist)	Clinic	Addis Ababa Vision & Eye Care Center
Location	Bole Road, Addis Ababa, Ethiopia	Contact	+251-11-555-0142 \| [email protected]
Client / Patient	[Name to be inserted]	Referral Source	[To be inserted]

This Quotation Estimate is issued by the Addis Ababa Vision & Eye Care Center to provide a comprehensive, itemized breakdown of anticipated costs for ophthalmological services rendered by a qualified Ophthalmologist operating in Ethiopia, Addis Ababa. This document serves as a formal financial projection for the patient, their family, or the referring insurance provider, and is intended to ensure full transparency regarding the scope of care, associated medical procedures, and all ancillary expenses that may be incurred during the course of treatment.

The Ophthalmologist named in this estimate, Dr. Alemu Tadesse, holds a Medical Doctor degree with a subspecialty in Ophthalmology, is a Fellow of the International Council of Ophthalmology (FICO), and has over fifteen years of clinical experience practicing in the Addis Ababa region of Ethiopia. All services outlined below are delivered in accordance with the standards set by the Ethiopian Food and Drug Authority (EFDA) and the Ethiopian Medical Association.

The following Quotation Estimate covers a full diagnostic and therapeutic ophthalmology package. The Ophthalmologist will conduct a complete eye examination, interpret diagnostic imaging, prescribe corrective measures, and, if clinically indicated, perform minor surgical interventions. All services are to be delivered at the clinic premises located in the Bole sub-city of Addis Ababa, Ethiopia, or at the designated surgical facility in the case of operative procedures.

#	Service / Procedure	Description	Qty	Unit Price (ETB)	Subtotal (ETB)
1	Comprehensive Ophthalmologist Consultation	Full history, visual acuity, refraction, slit-lamp exam, fundoscopy, intraocular pressure measurement	1 session	2,500	2,500
2	Dilated Fundus Examination	Pharmacologic mydriasis with direct and indirect ophthalmoscopy	1 session	1,200	1,200
3	Optical Coherence Tomography (OCT)	High-resolution cross-sectional imaging of the retina and optic nerve	1 scan	3,000	3,000
4	Visual Field Perimetry (Humphrey)	Automated perimetry for glaucoma and neurological assessment	1 test	2,000	2,000
5	Anterior Segment Biometry (IOL Master)	Axial length, corneal curvature measurement for cataract surgery planning	1 test	2,500	2,500
6	Phacoemulsification Cataract Surgery (per eye)	Ultrasound-assisted lens extraction with intraocular lens implantation, performed by the Ophthalmologist	1 eye	25,000	25,000
7	Intraocular Lens (IOL) – Premium Multifocal	AcrySof IQ Vivity or equivalent, single eye	1 unit	18,000	18,000
8	Post-Operative Ophthalmologist Follow-Up Visits	Three scheduled follow-up consultations (Day 1, Week 1, Month 1)	3 visits	1,500	4,500
9	Prescription Medications (30-day supply)	Topical antibiotics, corticosteroid drops, cycloplegics, and oral analgesics	1 course	3,500	3,500
10	Post-Operative Eye Shield & Protective Goggles	Rigid shield for sleep and UV-protective sunglasses	1 set	1,500	1,500
11	Emergency / Complication Management Reserve	Contingency allocation for intra-operative or post-operative complications requiring the Ophthalmologist's immediate intervention	1 allocation	5,000	5,000
TOTAL ESTIMATED COST					72,700
TOTAL IN US DOLLARS (approx. at 1 USD = 57 ETB)					~1,275 USD

This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, pricing may be subject to revision due to changes in pharmaceutical costs, exchange rate fluctuations in Ethiopia, or updated fee schedules of the Addis Ababa Vision & Eye Care Center.
All prices are quoted in Ethiopian Birr (ETB). The USD equivalent is provided for reference only and is calculated at the prevailing National Bank of Ethiopia (NBE) interbank rate on the date of issue. The final settlement shall be in ETB unless otherwise agreed in writing.
The Ophthalmologist reserves the right to modify the surgical plan intra-operatively if unforeseen anatomical conditions are encountered. Any additional procedures necessitated by such findings will be communicated to the patient or their authorized representative prior to execution, and a supplementary Quotation Estimate will be issued for approval.
A deposit of fifty percent (50%) of the total estimated amount is required at the time of scheduling the procedure. The remaining balance is due within seventy-two (72) hours following the completion of the surgical intervention.
This estimate does not include costs for general anesthesia if the patient opts for it over topical or peribulbar anesthesia. General anesthesia fees, as determined by the anesthesiologist at the partner hospital in Addis Ababa, will be itemized separately.
The Ophthalmologist and the clinic shall not be held liable for outcomes that fall outside the standard of care as defined by the Ethiopian Medical Association and the International Council of Ophthalmology. All surgical risks, including but not limited to infection, retinal detachment, and cystoid macular edema, are inherent to the procedure and are disclosed in the separate informed consent form.
Insurance claims: This Quotation Estimate can be submitted to the patient's health insurance provider (e.g., Ethiopian Social Insurance Agency, commercial insurers operating in Addis Ababa) for pre-authorization. The clinic will provide any additional documentation required by the insurer.
All medical records, diagnostic images, and surgical reports generated during the course of treatment will be retained by the clinic in Addis Ababa, Ethiopia, for a minimum of ten (10) years in compliance with Ethiopian health data regulations.

Important Note: This Quotation Estimate is a projection based on the clinical information available at the time of preparation. The final invoice may vary by up to ten percent (10%) depending on the complexity of the case, the number of follow-up visits required, and any additional diagnostic tests the Ophthalmologist deems necessary. The patient will be informed of any material deviation from this estimate before additional charges are incurred.

By signing below, the patient or their authorized legal representative acknowledges receipt of this Quotation Estimate, confirms understanding of the scope of Ophthalmologist services to be provided in Ethiopia, Addis Ababa, and authorizes the Addis Ababa Vision & Eye Care Center to proceed with the scheduled care as outlined herein.

For the Clinic / Ophthalmologist

Dr. Alemu Tadesse, MD, FICO
Lead Ophthalmologist

Patient / Authorized Representative

Name & Signature
Date

Witness

Name & Signature
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