Quotation Estimate Ophthalmologist in Switzerland Zurich –Free Word Template Download with AI

Seestrasse Ophthalmology Center
Ophthalmologist Practice & Surgical Unit
Seestrasse 245, 8002 Künzelsau
Switzerland Zurich, 8002
Tel: +41 44 555 0182
Email: [email protected] Quotation Estimate Date: 14 June 2025
Valid Until: 14 September 2025
Prepared By: Dr. med. Anna Keller, MD
Specialty: Ophthalmologist — Refractive & Cataract Surgery

Patient Name: Mr. Thomas Berger	Insurance Provider: Helsana AG
Address: Bahnhofstrasse 112, 8001 Switzerland Zurich	Policy Number: HSA-2025-77431
Date of Birth: 03 March 1971	Referring Physician: Dr. med. Lukas Meier, General Practitioner

This Quotation Estimate has been prepared by our Ophthalmologist team at Seestrasse Ophthalmology Center, located in the heart of Switzerland Zurich, to outline the anticipated costs for a comprehensive ophthalmological assessment and subsequent surgical intervention. The following services have been recommended following the initial consultation conducted on 28 May 2025 by Dr. med. Anna Keller, a board-certified Ophthalmologist with over 18 years of clinical experience in Switzerland Zurich.

No.	Service Description	Quantity	Unit Price (CHF)	Subtotal (CHF)
1	Comprehensive Ophthalmologist Consultation & Diagnostic Workup (visual acuity, intraocular pressure, slit-lamp examination, dilated fundus examination, OCT imaging, and biometry)	1 session	CHF 480.00	CHF 480.00
2	Pre-operative Ophthalmologist Assessment & Anesthesia Consultation (including blood work, ECG, and surgical risk evaluation)	1 session	CHF 320.00	CHF 320.00
3	Cataract Surgery — Phacoemulsification with Multifocal Intraocular Lens Implantation (performed by Ophthalmologist Dr. Keller, including operating room fees, surgical instruments, and IOL cost)	1 eye (OD)	CHF 3,850.00	CHF 3,850.00
4	Post-operative Ophthalmologist Follow-up Visits (Day 1, Week 1, Month 1, and Month 3 reviews including IOP check, suture assessment, and visual acuity monitoring)	4 visits	CHF 180.00	CHF 720.00
5	Prescription Medications (topical antibiotic drops, corticosteroid drops, and non-steroidal anti-inflammatory drops for 6 weeks post-surgery)	1 set	CHF 145.00	CHF 145.00
6	Additional Diagnostic Imaging (Anterior Segment OCT, Fundus Autofluorescence, and Visual Field Perimetry) if clinically indicated by the Ophthalmologist	1 set	CHF 290.00	CHF 290.00
7	Administrative & Documentation Fees (Quotation Estimate processing, medical report preparation, and insurance claim submission for Switzerland Zurich health providers)	1 set	CHF 95.00	CHF 95.00
TOTAL ESTIMATED COST (before insurance reimbursement):				CHF 6,000.00

Important Note: This Quotation Estimate reflects the full cost of Ophthalmologist services as practiced in Switzerland Zurich. The patient's supplementary insurance (Zusatzversicherung) through Helsana AG is expected to cover approximately 70% of the surgical and diagnostic components. The patient is responsible for the remaining co-payment (Selbstbehält) of CHF 300.00 per year as mandated by Swiss Federal Law (KVG). Final reimbursement amounts are subject to the terms of the patient's specific insurance policy.

Validity: This Quotation Estimate is valid for a period of 90 days from the date of issue. Prices are subject to revision in accordance with the current TARDOC fee schedule applicable to Ophthalmologist procedures in Switzerland Zurich.
Payment Terms: The patient is required to settle the co-payment portion within 14 days of the final invoice. The Ophthalmologist practice will submit the primary claim directly to the patient's insurance provider in Switzerland Zurich.
Scheduling: Upon acceptance of this Quotation Estimate, the Ophthalmologist team will coordinate a surgical date within 4 to 6 weeks. The patient must present a valid Swiss health insurance card (Krankenkassenkarte) at the time of admission.
Cancellation Policy: Cancellation of the scheduled Ophthalmologist procedure must be communicated in writing at least 72 hours in advance. A cancellation fee of CHF 250.00 applies for cancellations within 72 hours of the scheduled surgery.
Medical Necessity: The Ophthalmologist reserves the right to modify the scope of services if intra-operative findings necessitate additional interventions. Any such changes will be documented and communicated to the patient or their designated representative prior to proceeding.
Confidentiality: All medical records and Quotation Estimate documents are handled in strict compliance with the Swiss Federal Act on Data Protection (DSG) and the professional confidentiality obligations of the Ophthalmologist under Swiss medical law.
Governing Law: This Quotation Estimate and all associated Ophthalmologist services are governed by the laws of the Canton of Zurich, Switzerland Zurich. Any disputes shall be resolved through the competent courts of Switzerland Zurich.

By signing below, the patient acknowledges receipt of this Quotation Estimate for Ophthalmologist services in Switzerland Zurich, confirms understanding of the estimated costs, and authorizes the Ophthalmologist team at Seestrasse Ophthalmology Center to proceed with the outlined diagnostic and surgical plan.

Patient Signature
Mr. Thomas Berger
Date: ______________________ Ophthalmologist / Physician Signature
Dr. med. Anna Keller, MD
Seestrasse Ophthalmology Center, Switzerland Zurich
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX

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