Quotation Estimate Ophthalmologist in Vietnam Ho Chi Minh City –Free Word Template Download with AI

Quotation Estimate No: QTE-2025-04782
Date of Issue: 15 June 2025
Valid Until: 15 July 2025 Prepared For: Mr. Tran Van Minh
Address: 45 Le Duan Street, District 3, Ho Chi Minh City
Contact: +84 90 123 4567 Prepared By: Dr. Nguyen Thi Lan
Specialty: Ophthalmologist, MD, PhD
Department: Comprehensive Eye Care

Dear Mr. Tran Van Minh,

Thank you for your interest in the comprehensive ophthalmology services offered by Saigon Vision Ophthalmology Center in Vietnam Ho Chi Minh City. This Quotation Estimate has been carefully prepared following your initial consultation with our senior Ophthalmologist on 10 June 2025. The document below outlines the full scope of recommended diagnostic and therapeutic procedures, along with the associated costs for your review and approval.

No.	Service / Procedure Description	Quantity	Unit Price (VND)	Total (VND)
1	Comprehensive Ophthalmologist Consultation & Eye Examination (including visual acuity, refraction, intraocular pressure measurement, and slit-lamp biomicroscopy)	1 session	1,200,000	1,200,000
2	Dilated Fundus Examination with Optical Coherence Tomography (OCT) – performed by the Ophthalmologist to assess retinal health and detect early signs of macular degeneration	1 session	2,500,000	2,500,000
3	Corneal Topography & Pachymetry – detailed mapping of corneal curvature for contact lens fitting or pre-surgical planning	1 session	1,800,000	1,800,000
4	Phacoemulsification Cataract Surgery (monofocal intraocular lens implant) – performed by a board-certified Ophthalmologist with post-operative follow-up included	2 eyes	18,500,000	37,000,000
5	Post-Operative Ophthalmologist Follow-Up Visits (3 visits at 1 day, 1 week, and 1 month post-surgery)	3 visits	500,000	1,500,000
6	Prescription Medications & Ophthalmic Drops (antibiotic, anti-inflammatory, and lubricating drops for 30 days)	1 package	850,000	850,000
7	Annual Comprehensive Eye Health Screening (recommended for ongoing monitoring by the Ophthalmologist in Vietnam Ho Chi Minh City)	1 year	3,200,000	3,200,000
Subtotal				48,050,000 VND
VAT (10%)				4,805,000 VND
Grand Total				52,855,000 VND

Note: This Quotation Estimate is based on the clinical assessment conducted by our Ophthalmologist on 10 June 2025. Should additional procedures be identified during the surgical process, a supplementary estimate will be provided and approved by the patient or their authorized representative prior to any additional intervention. All prices are quoted in Vietnamese Dong (VND) and are inclusive of standard hospitalization fees at our facility in Vietnam Ho Chi Minh City.

Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, pricing may be subject to revision due to changes in medical supply costs or regulatory adjustments in Vietnam Ho Chi Minh City.
Payment Terms: A deposit of 50% of the total amount is required to confirm the surgical appointment. The remaining 50% is due within seven (7) days following the completion of all procedures and final Ophthalmologist follow-up.
Payment Methods: Bank transfer to Saigon Vision Ophthalmology Center (Account: 1020 8899 7766, Vietcombank, Ho Chi Minh City Branch), cash, or major credit cards (Visa, Mastercard).
Cancellation Policy: Cancellation of scheduled surgery more than 72 hours in advance incurs no charge. Cancellations within 72 hours are subject to a 20% administrative fee of the total Quotation Estimate amount.
Warranty: All surgical procedures performed by our Ophthalmologist carry a 12-month warranty covering re-intervention for surgical complications, excluding patient non-compliance with post-operative care instructions.
Confidentiality: All medical records and patient information are handled in strict accordance with Vietnam's Law on Medical Practice (2009) and the Personal Data Protection Decree 13/2023/NĐ-CP.
Insurance: This Quotation Estimate may be submitted to your health insurance provider for partial or full reimbursement. Our administrative team in Vietnam Ho Chi Minh City will assist with all necessary documentation.

By signing below, the patient or authorized representative acknowledges receipt of this Quotation Estimate, confirms understanding of the recommended Ophthalmologist procedures, and authorizes Saigon Vision Ophthalmology Center to proceed with the services described herein.

Patient / Authorized Representative
Name: ___________________________
Signature & Date: _______________ For Saigon Vision Ophthalmology Center
Dr. Nguyen Thi Lan – Lead Ophthalmologist
Signature & Date: _______________ ⬇️ Download as DOCX Edit online as DOCX

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