Quotation Estimate Ophthalmologist in South Africa Cape Town –Free Word Template Download with AI
Cape Town Vision & Eye Care Centre
124 Sea Point Promenade, Sea Point, Cape Town, 8005, South Africa
Phone: +27 21 424 5678 | Email: [email protected]
Registration No: 2019/123456/23 | HPCSA Practitioner No: 00456789
1. Parties to This Quotation EstimateService Provider (Ophthalmologist)
Cape Town Vision & Eye Care Centre
Lead Ophthalmologist: Dr. Naledi van der Merwe, MBChB, FCOphth(SA)
Address: 124 Sea Point Promenade, Sea Point
Cape Town, 8005, South Africa
VAT No: 4910234567
HPCSA No: 00456789
Client / Patient
Mr. Thabo Mokoena
Address: 87 Kloof Street, Gardens
Cape Town, 8001, South Africa
ID No: 8503125009087
Medical Aid: Discovery Health
Member No: DH-7845219
Phone: +27 82 345 6789
This Quotation Estimate is issued by our Ophthalmologist practice located in South Africa Cape Town to provide a comprehensive breakdown of all ophthalmic services, diagnostic procedures, and associated costs for the client named above. The following services have been recommended following the initial consultation conducted on 10 June 2025 at our Sea Point clinic in Cape Town, South Africa.
3. Itemised Cost Breakdown| Ref | Description of Ophthalmologist Service | Quantity | Unit Price (ZAR) | Total (ZAR) |
|---|---|---|---|---|
| 01 | Comprehensive Ophthalmologist Consultation & Eye Examination (including visual acuity, refraction, intraocular pressure measurement, and slit-lamp biomicroscopy) | 1 | R 1,250.00 | R 1,250.00 |
| 02 | Dilated Fundus Examination with Mydriatic Drops (Tropicamide 1% and Phenylephrine 2.5%) | 1 | R 450.00 | R 450.00 |
| 03 | Optical Coherence Tomography (OCT) – Macular & Retinal Nerve Fibre Layer Analysis | 2 | R 680.00 | R 1,360.00 |
| 04 | Automated Perimetry (Humphrey Visual Field Testing) – 24-2 Standard Threshold | 2 | R 520.00 | R 1,040.00 |
| 05 | Anterior Segment & Fundus Photography (Digital, 6 images per eye) | 1 | R 380.00 | R 380.00 |
| 06 | Corneal Topography & Pachymetry (for pre-surgical assessment) | 1 | R 550.00 | R 550.00 |
| 07 | Prescription of Custom Bifocal Spectacles (including lens dispensing, frame fitting, and 30-day adjustment period) | 1 | R 2,850.00 | R 2,850.00 |
| 08 | Follow-up Ophthalmologist Review (6 weeks post-prescription, including visual check and lens adaptation assessment) | 1 | R 650.00 | R 650.00 |
| 09 | Prescription Medication – Lubricating Eye Drops (Carboxymethylcellulose 0.5%, 10ml x 2 bottles) | 2 | R 185.00 | R 370.00 |
| 10 | Annual Comprehensive Eye Health Screening (next 12 months, includes all diagnostic tests listed in items 01–06) | 1 | R 3,200.00 | R 3,200.00 |
| Subtotal (Excluding VAT) | R 12,100.00 | |||
| VAT @ 15% (South Africa) | R 1,815.00 | |||
| GRAND TOTAL (Including VAT) | R 13,915.00 | |||
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, the Ophthalmologist practice reserves the right to revise pricing due to changes in consumable costs, medical aid tariffs, or operational expenses in South Africa Cape Town.
- All ophthalmologist services listed herein will be performed by Dr. Naledi van der Merwe or a qualified associate Ophthalmologist at the Cape Town Vision & Eye Care Centre, Sea Point, Cape Town, South Africa.
- Payment is due within fourteen (14) days of the date of this Quotation Estimate. Accepted payment methods include EFT (bank transfer), credit/debit card, and direct medical aid billing where the client's scheme permits.
- Should the client's medical aid (Discovery Health, Member No. DH-7845219) cover a portion of the fees, the Ophthalmologist practice will submit the claim electronically. The client is liable for any co-payment, gap cover shortfall, or non-covered items as per their policy terms.
- Cancellation of scheduled Ophthalmologist appointments must be made at least forty-eight (48) hours in advance. Late cancellations or no-shows will incur a fee of R 500.00 per session.
- All diagnostic imaging (OCT, perimetry, photography) will be stored in the client's secure electronic medical record at our Cape Town, South Africa facility in compliance with the Protection of Personal Information Act (POPIA) 2013.
- This Quotation Estimate does not constitute a guarantee of specific medical outcomes. The Ophthalmologist will exercise clinical judgement and may recommend additional or alternative procedures if clinically indicated during the course of treatment.
- Any disputes arising from this Quotation Estimate shall be resolved in accordance with the laws of the Republic of South Africa, with jurisdiction lying in the High Court of South Africa, Western Cape Division, Cape Town.
- The Ophthalmologist practice in South Africa Cape Town is registered with the Health Professions Council of South Africa (HPCSA) and operates in full compliance with all applicable South African health regulations and standards.
By signing below, the client acknowledges receipt of this Quotation Estimate for Ophthalmologist services in South Africa Cape Town and authorises the Cape Town Vision & Eye Care Centre to proceed with the services as itemised above, subject to the terms and conditions stated herein.
Client SignatureName: Thabo Mokoena
Date: ______________________ Ophthalmologist / Authorised Representative
Name: Dr. Naledi van der Merwe
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
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