Quotation Estimate Ophthalmologist in Saudi Arabia Jeddah –Free Word Template Download with AI
Professional Ophthalmologist Services — Saudi Arabia Jeddah
Ref: QE-OPH-2025-0472 Al Noor Vision & Eye Care CenterOphthalmologist Department
King Fahd Road, Al Shati District
Jeddah 23412, Saudi Arabia
Tel: +966-12-645-8900
Email: [email protected] Quotation Estimate Details
Date Issued: 15 June 2025
Valid Until: 15 July 2025
Currency: Saudi Riyal (SAR)
Prepared By: Dr. Khalid Al-Rashid, Consultant Ophthalmologist
License No.: MOH-OPH-2019-33847 Client / Patient Information
| Field | Details |
|---|---|
| Patient Name | Mr. Ahmed bin Salman Al-Otaibi |
| National ID / Iqama No. | 1098765432 |
| Contact Number | +966-55-123-4567 |
| Address | Al Rawdah District, Jeddah, Saudi Arabia |
| Referring Physician | Dr. Noura Al-Harbi, General Practitioner, Jeddah |
This Quotation Estimate has been prepared by our qualified Ophthalmologist team at Al Noor Vision & Eye Care Center, located in the heart of Saudi Arabia Jeddah, to provide a comprehensive and transparent cost breakdown for the recommended ophthalmic evaluation and treatment plan. All services listed below are delivered in accordance with the standards set by the Saudi Ministry of Health and the Saudi Food and Drug Authority (SFDA). The Ophthalmologist assigned to this case will conduct all examinations, consultations, and follow-up procedures within our fully accredited facility in Jeddah.
| Item No. | Description of Ophthalmologist Service | Qty | Unit Price (SAR) | Total (SAR) |
|---|---|---|---|---|
| 01 | Comprehensive Ophthalmologist Consultation & Initial Eye Examination (including visual acuity, refraction, and slit-lamp biomicroscopy) | 1 | 450.00 | 450.00 |
| 02 | Dilated Fundus Examination & Optical Coherence Tomography (OCT) performed by the Ophthalmologist | 1 | 380.00 | 380.00 |
| 03 | Intraocular Pressure Measurement (Tonometry) & Gonioscopy | 1 | 220.00 | 220.00 |
| 04 | Corneal Topography & Pachymetry Assessment | 1 | 350.00 | 350.00 |
| 05 | Color Vision Testing & Visual Field Analysis (Humphrey Perimetry) | 1 | 280.00 | 280.00 |
| 06 | Prescription of Corrective Lenses (Bifocal, 2 pairs) & Ophthalmologist Fitting Session | 2 | 650.00 | 1,300.00 |
| 07 | Follow-up Ophthalmologist Review (3 months post-treatment, includes re-examination and progress report) | 1 | 300.00 | 300.00 |
| 08 | Written Medical Report & Ophthalmologist Certification for Insurance / Employer Submission (Saudi Arabia Jeddah format) | 1 | 150.00 | 150.00 |
| Subtotal | 3,430.00 | |||
| VAT (15% — Saudi Arabia) | 514.50 | |||
| Grand Total (SAR) | 3,944.50 | |||
All prices are quoted in Saudi Riyal (SAR). This Quotation Estimate is valid for 30 calendar days from the date of issue. Prices are subject to revision should the Ophthalmologist recommend additional diagnostic or therapeutic procedures beyond the scope outlined above.
Terms & Conditions of This Quotation Estimate1. This Quotation Estimate for Ophthalmologist services is issued exclusively for the patient named above and is non-transferable. It reflects the current fee schedule of Al Noor Vision & Eye Care Center in Saudi Arabia Jeddah as of June 2025.
2. The Ophthalmologist reserves the right to modify the treatment plan based on clinical findings during the initial examination. Any additional procedures will be communicated to the patient prior to execution, and a supplementary Quotation Estimate will be provided for approval.
3. Payment is due within 14 days of acceptance of this Quotation Estimate. Accepted payment methods include bank transfer (Saudi National Bank, Al Rajhi Bank), credit/debit card, and cash at our Jeddah facility. A 5% late-payment surcharge applies after the due date.
4. This Quotation Estimate does not constitute a guarantee of specific medical outcomes. The Ophthalmologist will exercise all reasonable clinical judgment in the delivery of care in accordance with Saudi Arabian medical regulations.
5. All patient data and medical records are handled in strict compliance with the Saudi Personal Data Protection Law (PDPL) and the confidentiality policies of the Saudi Ministry of Health.
6. This Quotation Estimate is valid only for services rendered at our facility in Jeddah, Saudi Arabia. It does not cover travel, accommodation, or services at external laboratories unless explicitly stated.
7. In the event of cancellation by the patient after the Ophthalmologist has scheduled the appointment, a 20% administrative fee of the total Quotation Estimate value will be retained.
Acceptance & AuthorizationBy signing below, the patient (or authorized guardian) acknowledges receipt of this Quotation Estimate for Ophthalmologist services in Saudi Arabia Jeddah, agrees to the terms and conditions outlined above, and authorizes the Ophthalmologist team at Al Noor Vision & Eye Care Center to proceed with the recommended care plan.
For Al Noor Vision & Eye Care Center
Dr. Khalid Al-Rashid
Consultant Ophthalmologist
Patient / Authorized Guardian
Mr. Ahmed bin Salman Al-Otaibi
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