Quotation Estimate Ophthalmologist in Indonesia Jakarta –Free Word Template Download with AI

Quotation No.: QTE-JKT-OPH-2025-0472
Date Issued: 15 June 2025
Valid Until: 15 July 2025 (30 days) Prepared By: Dr. Anindya Wijaya, Sp.M(K)
Specialty: Ophthalmologist — Vitreoretinal Surgery
Clinic: Jakarta Vision Excellence Center
Address: Jl. Jend. Sudirman Kav. 52-53, SCBD, Indonesia Jakarta 12190 Client / Recipient Information

Patient Name:	Budi Santoso
Address:	Jl. Kemang Raya No. 88, Jakarta Selatan, Indonesia Jakarta 12730
Contact Number:	+62 812-3456-7890
Insurance Provider:	Prudential Indonesia (Policy No. PRD-2024-887123)
Referring Physician:	Dr. Ratna Dewi, Sp.PD (Internal Medicine)

Scope of Ophthalmologist Services — Indonesia Jakarta

This Quotation Estimate outlines the comprehensive ophthalmological care plan prepared by our senior Ophthalmologist at the Jakarta Vision Excellence Center, located in the heart of Indonesia Jakarta. The services below encompass a full diagnostic workup, surgical intervention, and post-operative follow-up for the treatment of bilateral diabetic retinopathy with macular edema. All procedures will be performed in accordance with the Indonesian Ministry of Health (Kemenkes) clinical guidelines and the standards set by the Indonesian Ophthalmology Society (PERDAMI).

Itemized Quotation Estimate Breakdown

No.	Service / Procedure	Qty	Unit Price (IDR)	Subtotal (IDR)
1	Comprehensive Ophthalmologist Consultation & Initial Assessment (including medical history review, visual acuity testing, and slit-lamp examination)	1 session	1,500,000	1,500,000
2	Dilated Fundus Examination & Optical Coherence Tomography (OCT) of both eyes	2 eyes	850,000	1,700,000
3	Fluorescein Fundus Angiography (FFA) — bilateral	2 eyes	1,200,000	2,400,000
4	Anterior & Posterior Segment B-Scan Ultrasound (for vitreous assessment)	2 eyes	450,000	900,000
5	Phacoemulsification Cataract Surgery with Premium IOL Implantation (right eye)	1 procedure	12,500,000	12,500,000
6	Pars Plana Vitrectomy (PPV) with Intravitreal Anti-VEGF Injection (left eye)	1 procedure	18,000,000	18,000,000
7	Intravitreal Anti-VEGF Injection (Aflibercept 2 mg) — follow-up injections (estimated 3 sessions over 12 weeks)	3 sessions	4,500,000	13,500,000
8	Post-Operative Ophthalmologist Follow-Up Visits (Week 1, Week 4, Month 3, Month 6, Month 12)	5 visits	750,000	3,750,000
9	Prescription Medications & Topical Ophthalmic Drops (post-surgical regimen, 6-week supply)	1 package	1,800,000	1,800,000
10	Operating Room Facility Fee & Anesthesia (local with sedation) — Jakarta Vision Excellence Center, Indonesia Jakarta	2 procedures	3,500,000	7,000,000
GRAND TOTAL (IDR)				63,050,000
Grand Total (USD Approx. @ 1 USD = 16,200 IDR)				~3,892.00 USD

Important Note: This Quotation Estimate is prepared specifically for the Ophthalmologist services rendered at our facility in Indonesia Jakarta. Prices are inclusive of VAT (PPN 11%) as mandated by the Indonesian tax authority (DJP). Insurance pre-authorization from Prudential Indonesia is required prior to scheduling surgical procedures. Any additional findings discovered during surgery may result in supplementary charges, which will be communicated to the patient or guardian in writing before proceeding. Terms & Conditions of This Quotation Estimate

1. Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, all prices are subject to revision based on current pharmaceutical costs, facility fees, and the prevailing exchange rate in Indonesia Jakarta.
2. Payment Terms: A minimum deposit of 50% of the total Quotation Estimate amount is required to secure the surgical schedule. The remaining balance is due within seven (7) business days following the completion of all procedures. Payment may be made via bank transfer (BCA, Mandiri, or BNI), credit card, or direct insurance claim settlement.
3. Insurance Coverage: The Ophthalmologist team will assist the patient in submitting all necessary documentation to the insurance provider. However, the final determination of coverage, co-payment percentages, and exclusions rests solely with the insurer. The patient is responsible for any uncovered portions.
4. Cancellation Policy: Cancellation of scheduled surgical procedures more than 14 days in advance incurs no penalty. Cancellations between 7 and 14 days incur a 25% administrative fee. Cancellations within 7 days of the scheduled date incur a 50% fee of the total Quotation Estimate.
5. Medical Consent: Prior to any surgical intervention, the patient (or legally authorized representative) must sign the informed consent form detailing the risks, benefits, and alternatives of the proposed Ophthalmologist procedures. The treating Ophthalmologist will ensure full comprehension of all medical information in Bahasa Indonesia or English.
6. Confidentiality: All patient records, diagnostic imaging, and treatment details are protected under the Indonesian Personal Data Protection Law (UU PDP No. 27 Tahun 2022). No information will be disclosed to third parties without written consent.
7. Dispute Resolution: Any disputes arising from this Quotation Estimate shall be resolved amicably. In the event of unresolved disagreement, matters shall be referred to the Indonesian Medical Council (Konsil Kedokteran Indonesia) or the relevant court of jurisdiction in Indonesia Jakarta.
8. Force Majeure: The clinic shall not be held liable for delays or cancellations caused by natural disasters, government mandates, pandemics, or other events beyond reasonable control.

Acceptance & Authorization

By signing below, the patient or authorized representative acknowledges receipt of this Quotation Estimate, confirms understanding of all listed Ophthalmologist services, and authorizes the Jakarta Vision Excellence Center to proceed with the outlined treatment plan in Indonesia Jakarta upon fulfillment of payment and insurance requirements.

Patient / Authorized Representative
Name: Budi Santoso
Date: _______________ Issuing Ophthalmologist
Dr. Anindya Wijaya, Sp.M(K)
Jakarta Vision Excellence Center
Indonesia Jakarta
Date: 15 June 2025 Clinic Administrator
Name: Sari Kusuma
Position: Head of Patient Services
Date: _______________

© 2025 Jakarta Vision Excellence Center — Indonesia Jakarta. This Quotation Estimate document is generated electronically and is valid without a physical stamp. Document Reference: QTE-JKT-OPH-2025-0472.

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