Quotation Estimate Ophthalmologist in Thailand Bangkok –Free Word Template Download with AI
Bangkok Eye & Vision Centre | 128 Sukhumvit Road, Khlong Toei, Bangkok 10110, Thailand
License No. TH-OPH-2024-0087 | Contact: +66-2-255-8899 | Email: [email protected]
Quotation Estimate No.: QE-2025-0417-BKK
Date of Issue: 15 June 2025
Valid Until: 15 July 2025 (30 days)
Prepared For: Mr. / Ms. [Patient Name]
Patient ID: BKC-2025-11482
Referring Ophthalmologist: Dr. Ananya Chaiyaporn, MD, FACS
1. Purpose of This Quotation EstimateThis Quotation Estimate has been prepared by Bangkok Eye & Vision Centre to provide a detailed and transparent cost breakdown for the full spectrum of Ophthalmologist services recommended for the patient listed above. All pricing in this document reflects the current 2025 fee schedule for Ophthalmologist consultations, diagnostic imaging, surgical interventions, and post-operative care available at our Thailand Bangkok facility. This Quotation Estimate is issued in accordance with the Thai Ministry of Public Health regulations governing medical service pricing transparency and patient informed consent requirements.
2. Scope of Ophthalmologist Services IncludedThe following Ophthalmologist services have been evaluated and are included in this Quotation Estimate. Each line item represents a distinct clinical service delivered by a board-certified Ophthalmologist or a qualified ophthalmic specialist under the direct supervision of the attending Ophthalmologist at our Thailand Bangkok location.
| No. | Service Description | Category | Qty | Unit Price (THB) | Subtotal (THB) |
|---|---|---|---|---|---|
| 1 | Initial Ophthalmologist Comprehensive Eye Examination (including visual acuity, refraction, intraocular pressure, and fundus examination) | Consultation | 1 | 2,500 | 2,500 |
| 2 | Optical Coherence Tomography (OCT) – Macular & Retinal Imaging | Diagnostic | 2 | 1,800 | 3,600 |
| 3 | Dilated Fundus Photography with Wide-Angle Retinal Imaging | Diagnostic | 1 | 1,200 | 1,200 |
| 4 | Corneal Topography & Pachymetry Assessment | Diagnostic | 1 | 1,500 | 1,500 |
| 5 | Phacoemulsification Cataract Surgery with Premium Toric Intraocular Lens Implantation (per eye) | Surgical | 2 | 45,000 | 90,000 |
| 6 | Pre-operative Ophthalmologist Consultation & Surgical Planning Session | Consultation | 1 | 3,000 | 3,000 |
| 7 | Post-operative Ophthalmologist Follow-up Visits (Week 1, Week 4, Month 3) | Follow-up | 3 | 1,500 | 4,500 |
| 8 | Prescription Medications – Topical Antibiotic & Anti-inflammatory Eye Drops (30-day supply) | Pharmacy | 1 | 2,200 | 2,200 |
| 9 | Post-surgical Protective Eyewear & Aftercare Kit | Supplies | 1 | 800 | 800 |
| 10 | Emergency Ophthalmologist On-call Coverage (24-hour post-operative period) | Support | 1 | 5,000 | 5,000 |
| SUBTOTAL (THB) | 114,300 | ||||
| VAT 7% (Thailand Value Added Tax) | 8,001 | ||||
| GRAND TOTAL (THB) | 122,301 | ||||
All Ophthalmologist services outlined in this Quotation Estimate will be performed at our Thailand Bangkok surgical and diagnostic centre, which is fully accredited by the Thai Joint Commission on Hospital Accreditation (TJCHA) and the International Society for Quality in Health Care (ISQua). The lead Ophthalmologist, Dr. Ananya Chaiyaporn, holds over 18 years of clinical experience in cataract surgery, refractive procedures, and retinal diagnostics. She is a Fellow of the American Academy of Ophthalmology (FACS) and a member of the Royal College of Ophthalmologists of Thailand. The surgical team includes two senior ophthalmic surgeons, four certified ophthalmic technicians, and a dedicated anaesthesiology team experienced in ophthalmic procedures.
4. Payment Terms & ConditionsThis Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. Payment for the full amount of THB 122,301 is due prior to the scheduled surgical date. The following payment methods are accepted at our Thailand Bangkok facility: bank transfer to the designated hospital account, major international credit cards (Visa, Mastercard, American Express), and cash in Thai Baht. A 50% deposit is required to confirm the surgical booking with the Ophthalmologist. The remaining balance is payable on the day of the procedure. International patients may request an itemised invoice for insurance reimbursement purposes.
Important Notes Regarding This Quotation Estimate:- All prices are quoted in Thai Baht (THB) and are subject to a 7% Value Added Tax (VAT) as mandated by Thai tax law.
- This Quotation Estimate does not include costs for additional diagnostic tests or unforeseen complications that may arise during the Ophthalmologist's surgical intervention.
- Any additional Ophthalmologist consultations or emergency visits beyond those listed will be billed separately at the standard Thailand Bangkok facility rate.
- International patients are advised to verify coverage with their travel or health insurance provider prior to accepting this Quotation Estimate.
- The Ophthalmologist reserves the right to modify the surgical plan based on intra-operative findings, in which case a revised Quotation Estimate will be presented and signed by the patient or their authorised representative before any additional procedures are performed.
- This document is a Quotation Estimate only and does not constitute a binding contract until formally accepted in writing by both parties.
By signing below, the patient (or legal guardian) acknowledges that they have received and reviewed this Quotation Estimate for Ophthalmologist services at the Thailand Bangkok facility. The patient confirms understanding of all costs, procedures, and conditions outlined herein and authorises Bangkok Eye & Vision Centre to proceed with the recommended Ophthalmologist care plan upon receipt of the required deposit.
Patient / Authorised Representative
Name: ______________________________
Signature: ______________________________
Date: ______________________________
Attending Ophthalmologist
Name: Dr. Ananya Chaiyaporn, MD, FACS
Signature: ______________________________
Date: ______________________________
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