Quotation Estimate Ophthalmologist in Philippines Manila –Free Word Template Download with AI

Quotation No.: QTE-2025-0714-003
Date Issued: July 14, 2025
Valid Until: August 14, 2025 Prepared For:
Mr. / Ms. [Patient Name]
[Patient Address, Philippines Manila]
Contact: [Phone Number] Prepared By:
Dr. [Ophthalmologist Name], MD
Board-Certified Ophthalmologist
Philippines Manila 1. Purpose of This Quotation Estimate

This Quotation Estimate is formally issued by Manila Vision & Eye Care Center to provide a comprehensive and transparent breakdown of all anticipated costs associated with the ophthalmological services to be rendered by our licensed Ophthalmologist in the Philippines Manila area. This document serves as a binding financial reference for the patient and their authorized representatives, ensuring full disclosure of all professional fees, diagnostic procedures, surgical interventions, and post-operative care costs. All pricing in this Quotation Estimate is presented in Philippine Pesos (PHP) and reflects the current standard rates as of the date of issuance in the Philippines Manila metropolitan region.

2. Scope of Ophthalmologist Services

The following Quotation Estimate covers the complete range of services to be performed by our senior Ophthalmologist at our facility located in the Philippines Manila district. The scope includes initial consultation, comprehensive diagnostic workup, surgical intervention (if applicable), and a minimum of three (3) post-operative follow-up consultations. All procedures will be conducted in accordance with the standards set by the Philippine Medical Association and the Philippine Retina Society.

3. Itemized Cost Breakdown

No.	Description of Service	Quantity	Unit Price (PHP)	Total (PHP)
1	Initial Consultation with Board-Certified Ophthalmologist (Philippines Manila)	1 session	2,500.00	2,500.00
2	Comprehensive Eye Examination (Visual Acuity, Intraocular Pressure, Funduscopy, Slit-Lamp Biomicroscopy)	1 session	3,200.00	3,200.00
3	OCT (Optical Coherence Tomography) Imaging	2 scans	1,800.00	3,600.00
4	Visual Field Testing (Perimetry)	1 session	1,500.00	1,500.00
5	Phacoemulsification Cataract Surgery (per eye) – performed by Ophthalmologist	2 eyes	45,000.00	90,000.00
6	Monofocal Intraocular Lens Implant (per eye)	2 lenses	12,000.00	24,000.00
7	Surgical Facility Fee (Operating Room, Anesthesia, Nursing – Philippines Manila)	2 procedures	15,000.00	30,000.00
8	Post-Operative Medications (Antibiotic Drops, Anti-inflammatory Drops, Lubricants – 30-day supply)	2 sets	2,800.00	5,600.00
9	Post-Operative Follow-Up Consultations with Ophthalmologist (Day 1, Week 1, Month 1)	6 visits	1,500.00	9,000.00
10	Emergency After-Care Consultation (if required within 30 days)	1 visit	2,000.00	2,000.00
11	Prescription Eyeglasses (Standard Frame + Lenses, Philippines Manila)	1 pair	8,500.00	8,500.00
GRAND TOTAL (PHP)				179,900.00

Note: This Quotation Estimate does not include costs for general anesthesia if the patient requires it instead of local anesthesia with sedation. An additional PHP 8,000.00 to PHP 12,000.00 may apply. All prices are subject to 12% VAT as mandated by the Bureau of Internal Revenue in the Philippines Manila jurisdiction. 4. Payment Terms and Conditions

Payment Schedule: A 50% down payment (PHP 89,950.00) is required upon acceptance of this Quotation Estimate to secure the surgical schedule with the Ophthalmologist. The remaining 50% balance shall be settled on the day of the surgical procedure.
Accepted Payment Methods: Cash, bank transfer (BDO, BPI, Metrobank), credit/debit cards (Visa, Mastercard), and HMO/PhilHealth co-pay arrangements are accepted at our Philippines Manila facility.
PhilHealth Coverage: This Quotation Estimate has been prepared to align with PhilHealth's maximum allowable charges (MAC) for cataract surgery. The patient's out-of-pocket expense will be the difference between the total quoted amount and the PhilHealth benefit, subject to eligibility verification.
Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. Prices may be adjusted after the validity period due to changes in medical supply costs or facility fee revisions in the Philippines Manila area.
Cancellation Policy: In the event the patient cancels the scheduled procedure, the 50% down payment is non-refundable if cancellation occurs within 72 hours of the scheduled surgery date. Cancellations made more than 72 hours in advance will receive a 75% refund of the down payment.
Warranty: The Ophthalmologist guarantees the surgical procedure for a period of ninety (90) days from the date of surgery. Any re-intervention required within this period due to surgical complications will be performed at no additional cost to the patient.

5. Acceptance and Authorization

By signing below, the patient or authorized representative acknowledges receipt of this Quotation Estimate and agrees to the terms, conditions, and pricing outlined herein for the ophthalmological services to be provided by the Ophthalmologist at Manila Vision & Eye Care Center, Philippines Manila. The patient confirms that all information has been explained in clear terms and that they have had the opportunity to ask questions regarding the scope of services, associated risks, and alternative treatment options.

Patient / Authorized Representative
Name: ______________________________
Signature: ______________________________
Date: ______________________________ Dr. [Ophthalmologist Name], MD
Board-Certified Ophthalmologist
Manila Vision & Eye Care Center
Philippines Manila
Signature: ______________________________
Date: ______________________________ ⬇️ Download as DOCX Edit online as DOCX

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