Quotation Estimate Ophthalmologist in India Bangalore –Free Word Template Download with AI
Bangalore, India Ophthalmology & Vision Care Quotation Estimate No. QTE-2025-0847
Quotation Estimate Reference: QTE-2025-0847Date of Issue: 15 June 2025
Valid Until: 15 July 2025 (30 days) Prepared By: Dr. Ananya Krishnamurthy, MD (Ophthalmology)
Clinic: VisionCare Ophthalmology Centre
Location: 42, Residency Road, Indiranagar, Bangalore, Karnataka 560038, India 1. Client / Patient Details
| Field | Details |
|---|---|
| Patient Name | Mr. Rajesh Kumar Nair |
| Address | 18, 12th Main, HSR Layout, Sector 2, Bangalore, Karnataka 560102, India |
| Contact Number | +91-98450-XXXXXX |
| [email protected] | |
| Referring Physician | Dr. S. Venkatesh, General Physician, Bangalore |
| Insurance Provider | Star Health & Allied Insurance, Policy No. SH-4482-XXXX |
This Quotation Estimate is issued by our qualified Ophthalmologist at VisionCare Ophthalmology Centre, Bangalore, India, to provide a detailed and transparent cost breakdown for the recommended ophthalmic diagnostic and therapeutic procedures. All services will be performed by a board-certified Ophthalmologist with over 18 years of clinical experience in comprehensive eye care in the Bangalore, India region.
| Sr. No. | Service / Procedure Description | Quantity | Unit Rate (INR) | Amount (INR) |
|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation & Initial Eye Examination (including visual acuity, refraction, intraocular pressure, and slit-lamp biomicroscopy) | 1 | 1,500 | 1,500 |
| 2 | Dilated Fundus Examination by Senior Ophthalmologist (including mydriatic drops and retinal assessment) | 1 | 800 | 800 |
| 3 | Optical Coherence Tomography (OCT) – Macular & Retinal Nerve Fibre Layer Analysis | 2 (OD & OS) | 1,200 | 2,400 |
| 4 | Automated Visual Field Testing (Humphrey 24-2) – Bilateral | 2 | 1,800 | 3,600 |
| 5 | Anterior Segment & Fundus Photography (Digital, 45-degree wide-angle) | 1 | 1,000 | 1,000 |
| 6 | Corneal Topography & Pachymetry (for pre-surgical assessment) | 1 | 1,500 | 1,500 |
| 7 | Phacoemulsification Cataract Surgery with Premium Toric IOL (per eye) – performed by Lead Ophthalmologist | 2 (Bilateral) | 45,000 | 90,000 |
| 8 | Post-Operative Ophthalmologist Follow-Up Visits (Week 1, Week 2, Month 1, Month 3) | 4 | 500 | 2,000 |
| 9 | Prescription Medications (Antibiotic & Anti-inflammatory eye drops – 30-day supply) | 1 | 2,200 | 2,200 |
| 10 | Custom Prescription Spectacles (CR-39 lenses, anti-reflective coating, metal frame) | 1 | 4,500 | 4,500 |
| Subtotal (INR) | 109,500 | |||
| GST @ 18% (as applicable under Indian healthcare tax regulations) | 19,710 | |||
| Grand Total (INR) | 129,210 | |||
| Insurance Coverage (Star Health – 80% reimbursement expected) | (103,368) | |||
| Patient Out-of-Pocket Amount (INR) | 25,842 | |||
The treating Ophthalmologist, Dr. Ananya Krishnamurthy, is a Fellow of the Royal College of Surgeons (FRCS) and a member of the Association for Research in Vision and Ophthalmology (ARVO). She has performed over 12,000 cataract surgeries and 3,500 refractive procedures at our Bangalore, India facility. The clinic is NABH-accredited and equipped with state-of-the-art diagnostic and surgical infrastructure, ensuring that every patient receiving an Ophthalmologist consultation in Bangalore, India receives world-standard care.
4. Terms & Conditions of This Quotation Estimate- Validity: This Quotation Estimate is valid for 30 days from the date of issue. Prices are subject to revision after the expiry period due to changes in medical supply costs in Bangalore, India.
- Payment Terms: 50% advance payment is required to schedule the Ophthalmologist surgical procedure. The remaining balance is due within 7 days of the final post-operative visit.
- Insurance: The patient is advised to confirm pre-authorization with their insurance provider. Our Ophthalmologist team in Bangalore, India will assist with all necessary documentation for claim processing.
- Cancellation Policy: In the event of cancellation by the patient, a 20% administrative fee of the total Quotation Estimate amount will be retained. Rescheduling is permitted up to 48 hours before the scheduled procedure at no additional cost.
- Medical Disclaimer: The final treatment plan may be modified by the treating Ophthalmologist based on intra-operative findings. Any additional procedures will be communicated to the patient prior to execution, and a revised Quotation Estimate will be issued.
- Warranty: The Ophthalmologist guarantees the surgical outcome for a period of 12 months. Any re-intervention required within this period due to surgical complications will be performed at no additional charge.
- Jurisdiction: This Quotation Estimate and all associated services are governed by the laws of India. Any disputes shall be subject to the exclusive jurisdiction of the courts in Bangalore, Karnataka, India.
- Confidentiality: All patient records, diagnostic images, and medical data handled by our Ophthalmologist team in Bangalore, India are protected under the Indian Digital Personal Data Protection Act, 2023.
By signing below, the patient (or authorized guardian) acknowledges receipt of this Quotation Estimate for Ophthalmologist services in Bangalore, India, and agrees to the terms and conditions outlined above. The treating Ophthalmologist confirms that all recommended procedures are clinically indicated based on the diagnostic findings.
Patient / Authorized Guardian
Name: _______________________________Signature: _______________________________
Date: _______________________________
Treating Ophthalmologist
Name: Dr. Ananya Krishnamurthy, MDSignature: _______________________________
Date: _______________________________
Reg. No.: KMC/2007/4821 ⬇️ Download as DOCX Edit online as DOCX
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