Quotation Estimate Optometrist in Belgium Brussels –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Reference No.: QTE-2025-BRU-00472

Date of Issue: 15 June 2025

Valid Until: 15 July 2025 (30 days)

Prepared By: Dr. Annelise Vermeulen, Optometrist

Currency: Euro (EUR)

Client Information

Name: Mr. Jean-Pierre De Smet

Address: Rue de la Loi 88, 1040 Brussels, Belgium

National Register No.: 85.12.34-567.89

Health Insurance: Mutualité Socialiste (MSB)

Policy No.: MSB-2025-448291

Dear Mr. De Smet,

Thank you for contacting our Optometrist practice in Belgium Brussels for a comprehensive eye examination and corrective lens prescription. This Quotation Estimate outlines the full scope of services, associated costs, and applicable terms for the ophthalmic care you have requested. Please review this document carefully before confirming your appointment. All prices listed below are in Euros (EUR) and include the applicable Belgian Value Added Tax (VAT) at the standard rate of 21%, unless otherwise noted.

Itemized Services & Pricing

Ref	Description of Service	Quantity	Unit Price (EUR)	Subtotal (EUR)	VAT (21%)
01	Comprehensive Optometrist Eye Examination (visual acuity, refraction, binocular vision, colour vision, and ocular health screening)	1	€ 85.00	€ 85.00	€ 17.85
02	Advanced Digital Retinal Imaging (fundus photography and OCT scan for early detection of retinal pathology)	1	€ 65.00	€ 65.00	€ 13.65
03	Prescription of Bifocal Progressive Lenses (premium aspheric design, anti-reflective and anti-scratch coating)	2	€ 120.00	€ 240.00	€ 50.40
04	Frame Selection & Fitting (titanium acetate frame, adjustable nose pads, and temple adjustment by our Optometrist)	1	€ 185.00	€ 185.00	€ 38.85
05	Post-Fitting Adjustment & Follow-Up Consultation (within 14 days of lens dispensing, included in Belgium Brussels practice protocol)	1	€ 0.00	€ 0.00	€ 0.00
06	Blue Light Filtering Coating (add-on for digital screen users, applied to both lenses)	2	€ 35.00	€ 70.00	€ 14.70
TOTAL AMOUNT DUE (EUR)				€ 645.00	€ 135.45
GRAND TOTAL (EUR)				€ 780.45

* Note: Under Belgian healthcare regulations, a portion of the Optometrist examination fee (€ 42.00) may be reimbursed by your mutualité (health insurance fund) upon submission of the official receipt. The remaining balance is the client's responsibility. Please retain this Quotation Estimate and the final invoice for your reimbursement claim.

Terms & Conditions of This Quotation Estimate

Validity: This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. Prices are subject to change after the expiry date due to supplier cost adjustments or modifications in Belgian tax legislation.
Payment Terms: A deposit of 40% (€ 312.18) is required at the time of booking to secure your appointment slot with our Optometrist in Belgium Brussels. The remaining balance of 60% (€ 468.27) is due upon collection of your finished eyewear. Payment may be made by bank transfer, credit card (Visa, Mastercard, Bancontact), or cash.
Delivery Timeline: Standard lens manufacturing and fitting is completed within ten (10) to fourteen (14) business days from the date of the Optometrist examination. Express service (5 business days) is available for an additional surcharge of € 50.00, which is not included in this Quotation Estimate.
Warranty: All lenses and frames dispensed by our practice carry a twelve-month warranty against manufacturing defects. This warranty does not cover damage caused by misuse, accidental breakage, or normal wear. The warranty is valid only within the territory of Belgium Brussels and the broader Flemish, Walloon, and Brussels-Capital regions.
Cancellation Policy: Should the client wish to cancel the appointment, the 40% deposit is non-refundable if cancellation occurs fewer than 72 hours before the scheduled Optometrist consultation. Cancellations made more than 72 hours in advance will receive a full refund of the deposit within five business days.
Regulatory Compliance: This Quotation Estimate and all associated services comply with the Royal Decree of 25 November 2003 governing the practice of optometry in Belgium, as well as the European Union General Data Protection Regulation (GDPR) regarding the handling of your personal and medical data.
Dispute Resolution: Any disputes arising from this Quotation Estimate shall be resolved under the jurisdiction of the competent courts of Brussels, Belgium. The client is encouraged to first contact the practice manager for amicable resolution before initiating formal legal proceedings.
Confidentiality: All medical records, prescription data, and examination results obtained during the Optometrist consultation are treated as strictly confidential in accordance with Belgian medical privacy law (Loi du 22 décembre 2013 relative aux droits du patient).

Acceptance & Authorization

By signing below, the client acknowledges that they have read, understood, and accepted all terms and conditions set forth in this Quotation Estimate. The client authorizes the Optometrist at Brussels Vision Care Centre to proceed with the services described herein and agrees to the payment schedule outlined above.

Client Signature
Mr. Jean-Pierre De Smet
Date: _______________ Optometrist / Practice Representative
Dr. Annelise Vermeulen
Brussels Vision Care Centre, Belgium Brussels
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX

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