Quotation Estimate Optometrist in Brazil Brasília –Free Word Template Download with AI
Optometrist & Ophthalmic Care Center
SHIS QI 05, Lote 12, Setor Habitacional Sul — Brasília, DF — CEP 71615-000
CNPJ: 12.345.678/0001-90 | Phone: +55 (61) 3344-5566 | Email: [email protected]
CRTO-DF: 4567/2024 | Registered Optometrist Practice in the Federal District
Quotation EstimateQuotation Details
Quotation No.: QE-2025-0847
Date of Issue: 15 June 2025
Valid Until: 15 July 2025 (30 days)
Location of Service: Brasília, Distrito Federal, Brazil
Currency: Brazilian Real (BRL / R$)
Client Information
Name: [Client Full Name]
CPF/CNPJ: [Client Tax ID]
Address: [Client Address], Brasília, DF
Phone: [Client Phone]
Email: [Client Email]
This Quotation Estimate is issued by Clínica Visão Brasília, a licensed Optometrist practice operating in the heart of Brazil Brasília, to provide a comprehensive and transparent breakdown of all professional optometric services requested by the client. As a registered Optometrist in the Federal District, our team is fully authorized by the Conselho Regional de Ótica e Optometria (CRTO) to perform all diagnostic, corrective, and preventive eye care procedures listed below. This document serves as a formal Quotation Estimate for the client's review, approval, and financial planning purposes.
| Item | Description of Optometrist Service | Quantity | Unit Price (R$) | Subtotal (R$) | Notes |
|---|---|---|---|---|---|
| 01 | Comprehensive Optometrist Eye Examination (refraction, visual acuity, binocular vision assessment, and ocular health screening) | 1 | R$ 350,00 | R$ 350,00 | Performed by a licensed Optometrist in Brasília |
| 02 | Advanced Digital Retinal Imaging (fundus photography and OCT scan for early detection of retinal pathologies) | 1 | R$ 280,00 | R$ 280,00 | Included in the Optometrist diagnostic package |
| 03 | Corneal Topography and Pachymetry (detailed corneal mapping for contact lens fitting or pre-surgical evaluation) | 1 | R$ 220,00 | R$ 220,00 | Optometrist specialist procedure |
| 04 | Binocular Vision Therapy & Vision Training Program (10 sessions of structured Optometrist-guided therapy for convergence insufficiency or amblyopia) | 10 | R$ 180,00 | R$ 1.800,00 | Weekly sessions at our Brasília clinic |
| 05 | Prescription of Custom Contact Lenses (fitting, trial, and follow-up by the Optometrist; includes 2 pairs of soft toric lenses) | 1 | R$ 1.200,00 | R$ 1.200,00 | Lenses supplied by authorized distributor in Brasília |
| 06 | Low Vision Assessment & Assistive Device Fitting (comprehensive evaluation by the Optometrist for patients with significant visual impairment) | 1 | R$ 400,00 | R$ 400,00 | Includes recommendation of magnifiers and electronic aids |
| 07 | Follow-up Optometrist Consultation (post-treatment review, prescription adjustment, and visual progress monitoring) | 2 | R$ 150,00 | R$ 300,00 | Scheduled at 30 and 90 days post-initial treatment |
| 08 | Written Optometrist Report & Medical Documentation (detailed clinical report in Portuguese and English, suitable for insurance or legal purposes in Brazil) | 1 | R$ 120,00 | R$ 120,00 | Delivered within 5 business days in Brasília |
| TOTAL QUOTATION ESTIMATE | R$ 4.670,00 | IVA (ICMS) included | |||
- Payment Schedule: This Quotation Estimate may be settled in a single payment or in up to three (3) equal installments via bank transfer (TED/PIX) to the account of Clínica Visão Brasília, located in Brasília, DF, Brazil. The first installment is due upon acceptance of this Quotation Estimate.
- Validity Period: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, prices for Optometrist services in Brasília may be subject to revision due to market conditions, supply costs, or regulatory changes in the Federal District.
- Cancellation Policy: Should the client wish to cancel any scheduled Optometrist appointment after this Quotation Estimate has been accepted, a 48-hour prior notice is required. Cancellations within 48 hours will incur a 50% fee on the scheduled session value.
- Insurance & Reimbursement: This Quotation Estimate is issued as a private-pay document. The client is responsible for verifying coverage with their health insurance provider (plano de saúde) in Brazil. Our Optometrist practice in Brasília can provide the necessary documentation for reimbursement claims.
- Regulatory Compliance: All Optometrist services described in this Quotation Estimate are performed in strict compliance with the regulations of the Conselho Federal de Ótica e Optometria (CFOTO) and the applicable health authority of the Distrito Federal, Brasília.
- Confidentiality: All patient data collected during the Optometrist consultation in Brasília is protected under Brazil's General Data Protection Law (LGPD — Lei Geral de Proteção de Dados, Law No. 13.709/2018).
By signing below, the client acknowledges receipt of this Quotation Estimate for Optometrist services to be rendered in Brazil Brasília and agrees to the terms, conditions, and pricing outlined in this document. The Optometrist practice at Clínica Visão Brasília will schedule the initial consultation within five (5) business days of written acceptance.
Client SignatureName: ______________________________
Date: ____ / ____ / 2025 Optometrist / Clínica Visão Brasília
Dr(a). ______________________________, Optometrist
CRTO-DF: 4567/2024
Date: ____ / ____ / 2025 ⬇️ Download as DOCX Edit online as DOCX
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