Quotation Estimate Ophthalmologist in Italy Rome –Free Word Template Download with AI
Ophthalmologist Diagnostic and Surgical Services — Italy Rome
Via dei Conciatori 24
00186 Roma (RM), Italy
P.IVA: IT01234567890
Tel: +39 06 4567 8901
Email: [email protected]
Website: www.clinicaoculisticaroma.it
Quotation No.: QE-2025-0487
Date of Issue: 14 June 2025
Valid Until: 14 July 2025 (30 days)
Prepared By: Dr. Marco Esposito, Ophthalmologist
Reference: Patient File #RM-2025-3312
| Field | Details |
|---|---|
| Patient Name | Signor/Signore [Full Name] |
| Address | [Street, Number], 001XX Roma (RM), Italy |
| Telephone | +39 [Number] |
| [Email Address] | |
| SSN Code (Codice Fiscale) | [16-character Italian tax code] |
| Referring Physician | Dr. [Name], [Specialty], [Clinic/Hospital in Rome] |
This Quotation Estimate has been prepared by the undersigned Ophthalmologist at Clinica Oculistica Roma, located in the historic centre of Italy Rome, to outline the full range of diagnostic, therapeutic, and surgical ophthalmological services proposed for the patient identified above. All procedures and consultations described herein comply with the regulations set forth by the Italian Ministry of Health (Ministero della Salute) and the professional standards of the Ordine dei Medici Chirurghi e degli Odontoiatri della Provincia di Roma.
| No. | Service / Procedure | Description | Qty | Unit Price (EUR) |
|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation | Initial full eye examination by a board-certified Ophthalmologist in Rome, including visual acuity testing, refraction, intraocular pressure measurement, slit-lamp biomicroscopy, and dilated fundus examination. Conducted at our clinic in the Rione Monti district of Italy Rome. | 1 | €120.00 |
| 2 | OCT (Optical Coherence Tomography) Imaging | High-resolution cross-sectional imaging of the retina, optic nerve, and macula to detect early signs of macular degeneration, glaucoma, or diabetic retinopathy. Performed on-site at our Italy Rome facility. | 2 | €95.00 |
| 3 | Visual Field Perimetry (Humphrey 24-2) | Computerised perimetric testing to map the peripheral and central visual fields, essential for glaucoma monitoring and neurological assessment. Administered by trained ophthalmic technicians under Ophthalmologist supervision. | 1 | €85.00 |
| 4 | Corneal Topography and Pachymetry | Detailed mapping of the anterior corneal surface and measurement of corneal thickness, required prior to any refractive surgery evaluation or contact lens fitting. Performed at our clinic in Italy Rome. | 1 | €75.00 |
| 5 | Phacoemulsification Cataract Surgery (per eye) | Micro-incision cataract extraction via phacoemulsification with implantation of a premium multifocal intraocular lens (IOL). Includes pre-operative anaesthetic drops, surgical fee of the Ophthalmologist, operating theatre charges, and one post-operative review. Performed at the accredited surgical suite in Italy Rome. | 2 | €1,850.00 |
| 6 | Post-Operative Follow-Up Visits | Three scheduled post-operative reviews by the treating Ophthalmologist at 1 day, 1 week, and 1 month post-surgery to monitor healing, intraocular pressure, and visual recovery. All visits at our Italy Rome clinic. | 3 | €60.00 |
| 7 | Prescription of Post-Operative Medication | Topical antibiotic and corticosteroid eye drops (30-day supply) as prescribed by the Ophthalmologist. Dispensed through the in-house pharmacy in compliance with Italian pharmaceutical regulations. | 1 | €45.00 |
| 8 | Annual Ophthalmologist Surveillance Package | Comprehensive annual re-examination including repeat OCT, visual field testing, and clinical review by the Ophthalmologist. Recommended for ongoing monitoring of treated conditions. Valid for one year from the date of the first visit in Italy Rome. | 1 | €250.00 |
| Description | Amount (EUR) |
|---|---|
| Subtotal — All Ophthalmologist Services | €5,430.00 |
| VAT (IVA) — 4% (medical services, Art. 10 DPR 633/72) | €217.20 |
| TOTAL AMOUNT DUE | €5,647.20 |
The total amount specified in this Quotation Estimate shall be settled as follows:
- 50% deposit (€2,823.60) due upon acceptance of this Quotation Estimate and scheduling of the surgical date.
- 50% balance (€2,823.60) due on the day of the surgical procedure or within 15 calendar days thereafter, whichever is earlier.
Accepted payment methods: bank transfer (bonifico bancario) to the IBAN provided on the official invoice, credit/debit card (Visa, Mastercard, American Express), or cash up to €4,999.99 in compliance with Italian anti-money-laundering regulations (D.Lgs. 231/2007). All transactions are processed in Euro (EUR) at our Italy Rome facility.
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After the expiry date, prices and availability of the Ophthalmologist's schedule may be subject to revision.
- All surgical and diagnostic procedures will be performed exclusively at the registered premises of Clinica Oculistica Roma, Via dei Conciatori 24, 00186 Roma (RM), Italy, or at an affiliated accredited hospital in the Rome metropolitan area if the patient's condition requires it.
- The treating Ophthalmologist reserves the right to modify the surgical plan intra-operatively if clinical findings necessitate additional or alternative interventions. Any such modifications will be communicated to the patient or their legal representative prior to or during the procedure, and any additional costs will be itemised on a supplementary Quotation Estimate.
- The patient is required to provide informed consent (consenso informato) in writing, in Italian or English, prior to any invasive procedure, in accordance with Law 219/2017 (Codice del consenso informato) and the professional code of the Italian Medical Association (FNOMCeO).
- Post-operative complications, if any, will be managed at no additional cost for a period of ninety (90) days following the surgical date. Beyond this period, follow-up consultations will be charged at the standard Ophthalmologist consultation rate of €120.00 per visit.
- This Quotation Estimate does not constitute a binding contract until formally accepted in writing by the patient and countersigned by the Ophthalmologist or the clinic's administrative director.
- All personal health data processed in connection with this Quotation Estimate and the subsequent treatment are handled in strict compliance with the EU General Data Protection Regulation (GDPR, Regulation 2016/679) and the Italian Data Protection Code (D.Lgs. 196/2003 as amended by D.Lgs. 101/2018).
By signing below, the patient acknowledges receipt of this Quotation Estimate for Ophthalmologist services in Italy Rome, confirms understanding of the proposed treatment plan, and authorises the Ophthalmologist and the clinic to proceed with the services described herein, subject to the terms and conditions outlined above.
Patient / Legal Representative
Name: ______________________________
Signature: ______________________________
Date: ______________________________
Ophthalmologist / Clinic Director
Dr. Marco Esposito, MD, PhD
Specialist in Ophthalmology — Italy Rome
Signature: ______________________________
Date: ______________________________
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT