Quotation Estimate Ophthalmologist in New Zealand Wellington –Free Word Template Download with AI
14 Lambton Quay, Wellington CBD, Wellington 6011, New Zealand
Phone: +64 4 472 8800 | Email: [email protected]
Provider No: 20-045-7812 | NZBN: 9429045678901
Quotation EstimateQuotation Details
Quotation No: WVEC-2025-04871
Date Issued: 12 June 2025
Valid Until: 12 September 2025 (90 days)
Prepared By: Dr. Sarah Mitchell, FRANZCO
Client / Patient Information
Name: [Patient Full Name]
Address: [Residential Address], Wellington, New Zealand
NZ Health Card No: [XXXX-XXXX-XXX]
Referring GP: Dr. James Tui, Te Aro Medical Centre
Dear Patient,
Thank you for choosing the Wellington Vision & Eye Care Centre for your ophthalmology needs. This Quotation Estimate has been prepared following your comprehensive ophthalmological assessment conducted on 5 June 2025 at our Wellington CBD clinic. As your treating Ophthalmologist, I have outlined below the recommended course of treatment, associated procedures, and the estimated costs involved. This Quotation Estimate is specific to your individual clinical presentation and is valid for a period of ninety (90) days from the date of issue.
The following Quotation Estimate covers the full spectrum of ophthalmological care recommended for your condition, including diagnostic imaging, surgical intervention where applicable, and post-operative follow-up consultations. All services are delivered by a registered Ophthalmologist holding Fellowship of the Royal Australasian College of Ophthalmologists (FRANZCO) and are conducted in accordance with the standards set by the New Zealand Medical Council and the Health and Disability Commissioner Act 1993.
| Ref | Service / Procedure Description | Quantity | Unit Price (NZD) | Total (NZD) |
|---|---|---|---|---|
| 01 | Comprehensive Ophthalmological Examination & Dilated Fundus Examination | 1 session | $320.00 | $320.00 |
| 02 | Optical Coherence Tomography (OCT) – Bilateral | 1 session | $185.00 | $185.00 |
| 03 | Anterior Segment & Gonioscopy Assessment | 1 session | $145.00 | $145.00 |
| 04 | Phacoemulsification Cataract Surgery (Right Eye) – including intraocular lens implant | 1 procedure | $2,850.00 | $2,850.00 |
| 05 | Phacoemulsification Cataract Surgery (Left Eye) – including intraocular lens implant | 1 procedure | $2,850.00 | $2,850.00 |
| 06 | Post-Operative Ophthalmologist Follow-Up Consultations (Week 1, Week 4, Month 3) | 3 sessions | $165.00 | $495.00 |
| 07 | Prescription Post-Operative Eye Drops (Steroidal & Antibiotic) | 1 course | $88.00 | $88.00 |
| 08 | Post-Operative Spectacle Dispensing & Fitting (Wellington Optician Partner) | 1 pair | $420.00 | $420.00 |
| 09 | Annual Ophthalmologist Surveillance Review (Year 1 post-surgery) | 1 session | $210.00 | $210.00 |
| Subtotal (NZD) | $7,563.00 | |||
| GST (15%) – New Zealand Goods and Services Tax | $1,134.45 | |||
| Grand Total (NZD) | $8,697.45 | |||
This Quotation Estimate is payable in accordance with the following terms. A deposit of 30% (NZD $2,609.24) is required at the time of booking to secure your surgical date at our Wellington facility. The remaining balance is due within fourteen (14) calendar days of the final post-operative consultation. We accept EFT, credit card (Visa, Mastercard, American Express), and HealthPlus / HIFA private health insurance claims. Please note that this Quotation Estimate does not include costs for any unforeseen intra-operative complications, which will be discussed and consented to separately by your Ophthalmologist prior to any additional intervention.
- This Quotation Estimate is a good-faith estimate of costs and is not a fixed-price guarantee. Actual charges may vary depending on clinical findings during the procedure.
- All ophthalmological services are performed by a qualified Ophthalmologist registered with the Medical Council of New Zealand. You are entitled to view our Ophthalmologist's registration and complaint history via the Health and Disability Commissioner website.
- This Quotation Estimate is valid for ninety (90) days from the date of issue. After this period, pricing may be subject to revision in line with Wellington regional medical fee schedules.
- Private health insurance (e.g., HIFA, HealthPlus, Medifund) may cover a portion of the ophthalmological procedures listed. We recommend contacting your insurer prior to accepting this Quotation Estimate to confirm your level of cover for cataract surgery and ophthalmologist consultations in New Zealand.
- Wellington Vision & Eye Care Centre operates under the Health and Safety at Work Act 2015 and maintains full professional indemnity and public liability insurance as required for ophthalmological practice in New Zealand.
- Should you wish to decline any portion of the recommended ophthalmological treatment outlined in this Quotation Estimate, please inform our clinic in writing. Your Ophthalmologist will document your informed decision in your clinical file.
- All patient records and ophthalmological imaging data are stored in compliance with the New Zealand Privacy Act 2020 and the Health Information Privacy Code 1994.
By signing below, you acknowledge that you have read and understood this Quotation Estimate for ophthalmological services provided by your treating Ophthalmologist at Wellington Vision & Eye Care Centre, New Zealand. You confirm that you have had the opportunity to ask questions regarding the recommended treatment plan, associated risks, and alternative options. Your signature constitutes acceptance of the estimated costs and payment terms outlined above.
Patient / Authorised Representative
Signature | Full Name | Date
Dr. Sarah Mitchell, FRANZCO
Ophthalmologist – Wellington Vision & Eye Care Centre
Signature | Date
⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
GoGPT