Quotation Estimate Optometrist in Canada Montreal –Free Word Template Download with AI
Optometrist Professional Services — Canada Montreal
Document No: QTE-2025-0847Provider (Optometrist Practice)
Dr. Catherine Moreau, O.D.
Clinique d'Optométrie du Centre-Ville
1450 Rue Sainte-Catherine Ouest, Bureau 320
Montreal, Quebec, Canada H3G 1X4
Phone: (514) 555-0192
Email: [email protected]
License No: Q-2019-44782 (Ordre des optométristes du Québec)
Client / Recipient
Mr. Jonathan Tremblay
2847 Avenue du Parc
Montreal, Quebec, Canada H2X 3B7
Phone: (514) 555-0347
Email: [email protected]
Insurance: Sun Life Vision Plan #SL-882341
Quotation Details
Date of Issue: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Payment Terms: Net 15 days from acceptance
Currency: Canadian Dollars (CAD)
Service Location
Canada Montreal Clinic
1450 Rue Sainte-Catherine Ouest
Montreal, Quebec, Canada
Hours: Mon–Fri, 8:00 AM – 6:00 PM
Saturday: 9:00 AM – 1:00 PM
This Quotation Estimate outlines the comprehensive optometrist services to be provided to the client at our Canada Montreal clinic. The following line items represent the full scope of the recommended optometrist assessment and corrective care plan, as discussed during the initial consultation on June 5, 2025.
| # | Service Description | Optometrist Procedure | Qty | Unit Price (CAD) | Subtotal (CAD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Optometrist Eye Examination | Full diagnostic assessment | 1 | $185.00 | $185.00 |
| 2 | Dilated Fundus Examination (Retinal Screening) | Optometrist retinal imaging | 1 | $65.00 | $65.00 |
| 3 | Corneal Topography & Pachymetry | Optometrist corneal mapping | 1 | $95.00 | $95.00 |
| 4 | Visual Field Perimetry (Humphrey 30-2) | Optometrist peripheral vision test | 1 | $120.00 | $120.00 |
| 5 | Binocular Vision & Ocular Motility Assessment | Optometrist alignment evaluation | 1 | $75.00 | $75.00 |
| 6 | Prescription for Bifocal Progressive Lenses (Pair) | Optometrist lens dispensing | 1 | $420.00 | $420.00 |
| 7 | Anti-Reflective & Blue-Light Coating (Both Lenses) | Optometrist lens treatment | 2 | $45.00 | $90.00 |
| 8 | Follow-Up Optometrist Consultation (4 weeks post-dispensing) | Optometrist adjustment visit | 1 | $50.00 | $50.00 |
Terms & Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, the Optometrist practice reserves the right to revise pricing based on current supply costs and service availability in Canada Montreal.
- All optometrist services listed herein will be performed by Dr. Catherine Moreau, O.D., or a qualified optometrist associate at the Canada Montreal clinic, in accordance with the standards set by the Ordre des optométristes du Québec.
- Payment is due within fifteen (15) business days of the client's written acceptance of this Quotation Estimate. Late payments may incur a 1.5% monthly interest charge as permitted under Quebec consumer protection legislation.
- The insurance reimbursement amount of $350.00 is an estimate based on the client's Sun Life Vision Plan benefits. The final reimbursement is subject to the insurer's approval and may vary. The client is responsible for any difference between the estimated and actual reimbursement.
- Should the client require additional optometrist procedures not listed in this Quotation Estimate (e.g., contact lens fitting, additional diagnostic imaging, or referral to an ophthalmologist), a supplementary Quotation Estimate will be issued prior to any additional service being rendered.
- All corrective lenses dispensed under this Quotation Estimate carry a twelve-month warranty against manufacturing defects. The warranty does not cover damage caused by misuse, accidental breakage, or normal wear.
- This Quotation Estimate does not constitute a medical diagnosis. The Optometrist examination results and recommendations are provided for the purpose of corrective vision care. Any suspected pathological condition will be referred to a qualified ophthalmologist in Canada Montreal for further evaluation.
- Client personal health information collected during the optometrist examination will be handled in strict compliance with the Privacy Act (Quebec) and the Personal Health Information Protection Act (PHIPA) of Canada.
- Acceptance of this Quotation Estimate may be confirmed by signing below, by email reply to the Optometrist practice, or by verbal confirmation during a scheduled appointment at the Canada Montreal clinic.
Prepared by (Optometrist):
Dr. Catherine Moreau, O.D.Clinique d'Optométrie du Centre-Ville
Date: _______________
Accepted by (Client):
Mr. Jonathan TremblaySignature: _______________
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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