Quotation Estimate Optometrist in Israel Jerusalem –Free Word Template Download with AI
Comprehensive Optometrist Services & Vision Care
Jerusalem, Israel — Serving the Israel Jerusalem Community
Official Quotation Estimate Document Client Information| Field | Details |
|---|---|
| Client Name: | Mr. David Levi |
| Address: | 18 Herzl Boulevard, Jerusalem, Israel 97100 |
| Phone: | +972-52-784-3321 |
| Email: | [email protected] |
| National Insurance No.: | 048-XXXX-XXX |
| Health Insurance Provider: | Maccabi Health Services, Israel Jerusalem Branch |
The following Quotation Estimate outlines the complete scope of Optometrist services, diagnostic procedures, and vision correction products recommended for the client. All prices are listed in New Israeli Shekels (NIS / ILS) and are inclusive of the applicable 18% Value Added Tax (VAT) as mandated by the Israel Jerusalem tax authority.
| # | Service / Product Description | Category | Qty | Unit Price (NIS) | Subtotal (NIS) |
|---|---|---|---|---|---|
| 1 | Comprehensive Optometrist Eye Examination (including refraction, visual field assessment, and binocular vision testing) | Diagnostic | 1 | 350.00 | 350.00 |
| 2 | Dilated Fundus Examination with Digital Retinal Photography (both eyes) | Diagnostic | 1 | 280.00 | 280.00 |
| 3 | Corneal Topography & Pachymetry (advanced Optometrist diagnostic mapping) | Diagnostic | 1 | 420.00 | 420.00 |
| 4 | Intraocular Pressure Measurement (Gonioscopy & Tonometry) | Diagnostic | 1 | 180.00 | 180.00 |
| 5 | Progressive Multifocal Contact Lenses (pair, premium brand, Israel Jerusalem approved) | Product | 1 | 1,250.00 | 1,250.00 |
| 6 | Anti-Reflective, Blue-Light Filtering, Polarized Prescription Eyeglass Lenses (pair) | Product | 1 | 1,850.00 | 1,850.00 |
| 7 | Acetate Optical Frame (Italian design, Israel Jerusalem exclusive collection) | Product | 1 | 980.00 | 980.00 |
| 8 | Optometrist Fitting & Dispensing Session (lens adaptation, frame adjustment, and aftercare consultation) | Service | 1 | 200.00 | 200.00 |
| 9 | Follow-Up Optometrist Review Appointment (6 weeks post-dispensing) | Service | 1 | 150.00 | 150.00 |
| 10 | Annual Eye Health Screening Plan (12-month subscription, Israel Jerusalem residents) | Subscription | 1 | 600.00 | 600.00 |
| TOTAL QUOTATION ESTIMATE AMOUNT (incl. 18% VAT): | 6,260.00 NIS | ||||
- Validity: This Quotation Estimate remains valid for thirty (30) calendar days from the date of issue. After the expiry date, pricing may be subject to revision based on supplier costs and Israel Jerusalem market conditions.
- Payment Terms: Full payment is due upon acceptance of this Quotation Estimate. We accept bank transfer (NIS), credit/debit cards, and installment plans (up to 6 months interest-free) for Optometrist product purchases exceeding 1,000 NIS.
- Insurance Reimbursement: A portion of the Optometrist diagnostic services listed in this Quotation Estimate may be eligible for reimbursement through the client's health insurance provider (Maccabi, Clalit, Meuhedet, or Assikhat HaLeumit). Our Israel Jerusalem billing office will assist with all necessary documentation and claim submissions.
- Warranty: All prescription lenses and optical frames carry a 12-month manufacturer warranty. Contact lens solutions and disposables are non-returnable once opened. The Optometrist fitting guarantee covers frame adjustments for 90 days.
- Cancellation & Rescheduling: Appointments for Optometrist services may be rescheduled up to 24 hours in advance without penalty. Cancellations within 24 hours may incur a 50% service fee.
- Regulatory Compliance: All services rendered under this Quotation Estimate comply with the regulations set forth by the Israel Jerusalem Ministry of Health and the Israeli Optometric Association. Our practice holds a valid license number JLM-OPH-2019-0042.
- Confidentiality: All patient records, diagnostic images, and prescription data are handled in strict accordance with Israel's Privacy Protection Law, 5741-1981, and the Israel Jerusalem medical data protection guidelines.
- Acceptance: By signing below, the client acknowledges receipt of this Quotation Estimate and agrees to the terms outlined herein. The Optometrist practice will commence services upon receipt of the signed document and applicable payment.
| Client Signature | Optometrist / Authorized Representative |
|---|---|
|
Name: David Levi Signature: _________________________ Date: _______________ |
Name: Dr. Sarah Cohen, O.D. License No.: JLM-OPH-2019-0042 Signature: _________________________ Date: _______________ |
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