Quotation Estimate Ophthalmologist in Japan Kyoto –Free Word Template Download with AI
12-34 Higashiyama-ku, Kyoto-shi, Kyoto-fu 605-0001, Japan
Tel: +81-75-123-4567 | Email: [email protected]
Medical License No. KY-2019-0847 | JCI Accredited Facility
Quotation EstimateQuotation Details
Quotation No.: QTE-2025-KYO-0347
Date of Issue: June 15, 2025
Valid Until: July 15, 2025
Prepared By: Dr. Haruki Tanaka, MD, PhD
Specialty: Ophthalmologist – Comprehensive Eye Care
Client Information
Client Name: [Client / Insurance Provider Name]
Address: [Client Address], Japan
Contact: [Phone / Email]
Insurance Ref.: [National Health Insurance / Private]
Referring Physician: [If Applicable]
This Quotation Estimate is issued by the undersigned Ophthalmologist at Kyoto Vision & Eye Care Center, located in the heart of Japan Kyoto, to provide a comprehensive and transparent breakdown of anticipated costs for the ophthalmic services, diagnostic procedures, and therapeutic interventions outlined below. This document serves as a formal financial projection and does not constitute a binding invoice until all services have been rendered and confirmed by the treating physician.
Itemized Services and Cost Breakdown| No. | Service / Procedure Description | Category | Qty | Unit Price (JPY) | Subtotal (JPY) |
|---|---|---|---|---|---|
| 1 | Comprehensive Ophthalmologist Consultation & Initial Eye Examination (including visual acuity, refraction, and slit-lamp biomicroscopy) | Consultation | 1 | ¥12,000 | ¥12,000 |
| 2 | Dilated Fundus Examination with Optical Coherence Tomography (OCT) – Bilateral | Diagnostics | 1 | ¥18,500 | ¥18,500 |
| 3 | Automated Perimetry (Visual Field Testing) – Goldmann / Humphrey 24-2 | Diagnostics | 1 | ¥9,800 | ¥9,800 |
| 4 | Anterior Segment & Posterior Segment Photography (Digital, 4K Resolution) | Diagnostics | 1 | ¥7,200 | ¥7,200 |
| 5 | Corneal Topography & Pachymetry (for refractive surgery evaluation) | Diagnostics | 1 | ¥11,000 | ¥11,000 |
| 6 | Phacoemulsification Cataract Surgery with Premium Toric IOL Implantation – Bilateral | Surgical | 2 | ¥380,000 | ¥760,000 |
| 7 | Post-Operative Follow-Up Visits (4 sessions over 6 weeks) – Ophthalmologist Supervised | Follow-Up | 4 | ¥6,500 | ¥26,000 |
| 8 | Prescription Medications (Antibiotic & Anti-inflammatory Eye Drops, 30-day supply) | Pharmacy | 1 | ¥4,800 | ¥4,800 |
| 9 | Custom Prescription Spectacle Lenses (High-Index 1.67, Anti-Reflective Coating) | Optics | 1 | ¥32,000 | ¥32,000 |
| 10 | Annual Comprehensive Eye Health Screening Package (for ongoing Ophthalmologist care in Japan Kyoto) | Preventive | 1 | ¥25,000 | ¥25,000 |
| GRAND TOTAL (Before Tax) | ¥906,300 | ||||
| Consumption Tax (10%) | ¥90,630 | ||||
| TOTAL AMOUNT DUE | ¥996,930 | ||||
Note: This Quotation Estimate reflects the standard fee schedule of our Ophthalmologist practice in Japan Kyoto as of June 2025. Costs for surgical procedures (Item 6) are subject to a 50% deposit at the time of surgical scheduling. All diagnostic and consultation fees are eligible for reimbursement under Japan's National Health Insurance (NHI) system at the standard 30% co-payment rate for eligible patients. Private insurance claims may be processed separately upon request.
Terms and Conditions1. This Quotation Estimate is valid for a period of thirty (30) days from the date of issue. After the expiration date, all fees are subject to revision based on current pricing at our Japan Kyoto facility.
2. The treating Ophthalmologist reserves the right to modify the scope of services if clinical findings during examination necessitate additional or alternative procedures. Any such modifications will be communicated to the client in writing prior to implementation, and a revised Quotation Estimate will be issued.
3. Payment is due within fourteen (14) days of the date of service completion. Accepted payment methods include bank transfer (Japan domestic and international wire), credit card (Visa, Mastercard, JCB), and cash at our Japan Kyoto reception office.
4. Cancellation of scheduled surgical procedures must be communicated at least seventy-two (72) hours in advance. Cancellations within 72 hours will incur a 20% administrative fee on the scheduled procedure cost.
5. All medical records, diagnostic imaging, and OCT data generated during the course of treatment at this Ophthalmologist practice in Japan Kyoto shall remain the property of the facility and the patient jointly, in accordance with Japan's Personal Information Protection Act (PIPA).
6. This Quotation Estimate does not guarantee specific clinical outcomes. The Ophthalmologist will exercise the highest standard of care in accordance with the Japanese Ophthalmological Society guidelines and applicable medical ethics codes.
7. In the event of emergency complications requiring unscheduled intervention, additional fees will be assessed at the standard emergency rate and itemized on a supplementary Quotation Estimate provided within five (5) business days.
Acceptance and AuthorizationBy signing below, the client acknowledges receipt of this Quotation Estimate, confirms understanding of the itemized costs for the Ophthalmologist services in Japan Kyoto, and authorizes the facility to proceed with the described treatments and procedures.
Client Signature: ___________________________
Name (Printed): ___________________________
Date: ___________________________
Ophthalmologist / Authorized Representative:
Dr. Haruki Tanaka, MD, PhD
Kyoto Vision & Eye Care Center, Japan Kyoto
Date: June 15, 2025
Seal (Hanko): [Official Practice Seal]
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