Quotation Estimate Ophthalmologist in Israel Jerusalem –Free Word Template Download with AI
Comprehensive Ophthalmologist Services — Israel Jerusalem
Ref. No: QTE-JER-2025-04871 | Date: 15 June 2025
Issued By:Mount Zion Ophthalmology Center
12 Herzl Street, Jerusalem 91000, Israel
Tel: +972-2-623-4567
Email: [email protected]
License No: IL-OPH-2019-00342 Prepared For:
Mr. David Levi
45 King George Street
Jerusalem 94000, Israel
Tel: +972-52-887-6543
Email: [email protected] 1. SCOPE OF SERVICES — Ophthalmologist Consultation & Treatment Plan
This Quotation Estimate is issued by Mount Zion Ophthalmology Center, a licensed and accredited medical facility located in the heart of Israel Jerusalem, to provide a detailed financial breakdown for the full spectrum of Ophthalmologist services recommended for the patient named above. The following services have been identified following an initial screening consultation conducted on 10 June 2025 by Dr. Sarah Ben-Ami, Senior Ophthalmologist, and her specialized team.
Note: This Quotation Estimate reflects the standard pricing structure for Ophthalmologist services in Israel Jerusalem as of June 2025. All prices are quoted in New Israeli Shekels (NIS / ILS) and are inclusive of VAT (18%) where applicable. 2. ITEMIZED SERVICES & PRICING| # | Service Description | Ophthalmologist / Specialist | Qty | Unit Price (NIS) | Subtotal (NIS) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation & Diagnostic Assessment (including visual acuity testing, intraocular pressure measurement, and slit-lamp examination) | Dr. Sarah Ben-Ami, MD | 1 | 450.00 | 450.00 |
| 2 | Dilated Fundus Examination & Optical Coherence Tomography (OCT) of the retina | Dr. Sarah Ben-Ami, MD | 1 | 680.00 | 680.00 |
| 3 | Corneal Topography & Pachymetry (advanced mapping of the corneal surface) | Dr. Yossi Katz, MD | 1 | 520.00 | 520.00 |
| 4 | Anterior Segment Ultrasound (B-Scan) for posterior segment evaluation | Dr. Yossi Katz, MD | 1 | 390.00 | 390.00 |
| 5 | Fluorescein Fundus Angiography (FFA) — full diagnostic imaging of retinal vasculature | Dr. Sarah Ben-Ami, MD | 1 | 850.00 | 850.00 |
| 6 | Phacoemulsification Cataract Surgery with Premium Toric Intraocular Lens Implantation (per eye) | Dr. Michael Rosen, MD (Surgeon) | 2 | 7,200.00 | 14,400.00 |
| 7 | Post-Operative Ophthalmologist Follow-Up Visits (4 visits over 6 weeks) | Dr. Sarah Ben-Ami, MD | 4 | 280.00 | 1,120.00 |
| 8 | Prescription Medications & Post-Operative Eye Drops (30-day supply) | Pharmacy | 1 | 340.00 | 340.00 |
| 9 | Custom Prescription Spectacles — Frame and Lenses (post-surgical correction) | Optical Department | 1 | 1,200.00 | 1,200.00 |
| 10 | Annual Ophthalmologist Monitoring & Preventive Eye Health Check (12-month package) | Dr. Sarah Ben-Ami, MD | 1 | 950.00 | 950.00 |
| SUBTOTAL (excl. VAT): | 20,900.00 | ||||
| VAT (18%): | 3,762.00 | ||||
| TOTAL AMOUNT DUE (NIS): | 24,662.00 | ||||
- Validity: This Quotation Estimate for Ophthalmologist services in Israel Jerusalem is valid for a period of sixty (60) calendar days from the date of issue. After this period, pricing may be subject to revision based on updated medical supply costs and regulatory adjustments.
- Payment Schedule: A deposit of 30% (NIS 7,398.60) is required at the time of acceptance to reserve the Ophthalmologist surgical slot. The remaining 70% balance is due within fourteen (14) days following the completion of all surgical and post-operative procedures.
- Insurance & Coverage: The patient is advised to verify coverage with their respective health fund (Maccabi, Clalit, Meuhedet, or Assikhat HaLeumit) prior to acceptance. This Quotation Estimate reflects private-pay rates. Reimbursable portions under Israeli national health insurance (Kupat Cholim) will be deducted where applicable.
- Surgical Scheduling: The Ophthalmologist surgical team in Israel Jerusalem will coordinate a specific date within 30 days of deposit confirmation. Rescheduling is permitted up to 72 hours prior to the scheduled procedure without penalty.
- Medical Clearance: Prior to any surgical intervention, the patient must provide a general physician clearance letter and a complete medical history. The treating Ophthalmologist reserves the right to modify the treatment plan based on intra-operative findings.
- Warranty: All surgical procedures performed by the Ophthalmologist team carry a 12-month clinical warranty covering re-intervention for complications directly attributable to the surgical technique. This does not cover progressive age-related conditions.
- Confidentiality: All medical records, imaging data, and financial information contained in this Quotation Estimate are protected under Israeli Privacy Law (5741-1981) and the Medical Treatment Law (5722-1962).
- Dispute Resolution: Any disputes arising from this Quotation Estimate shall be resolved in accordance with the jurisdiction of the Jerusalem District Court, Israel.
By signing below, the patient (or authorized representative) acknowledges receipt of this Quotation Estimate, confirms understanding of the recommended Ophthalmologist treatment plan, and authorizes Mount Zion Ophthalmology Center to proceed with the services listed herein in Israel Jerusalem.
Patient / Authorized RepresentativeName: _________________________
Signature: _________________________
Date: _________________________ Mount Zion Ophthalmology Center
Name: Dr. Sarah Ben-Ami, MD
Title: Senior Ophthalmologist & Medical Director
Signature: _________________________
Date: _________________________ ⬇️ Download as DOCX Edit online as DOCX
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