Quotation Estimate Optometrist in United States Chicago –Free Word Template Download with AI
Lakeview Vision & Optometry Center
1420 N. Michigan Avenue, Suite 850, Chicago, Illinois 60610, United States
Phone: (312) 555-0198 | Email: [email protected]
Quotation Estimate No. QE-2025-04872Prepared For:
Mr. Jonathan R. Whitfield
2847 W. Fullerton Avenue
Chicago, Illinois 60647, United States
Phone: (773) 555-4421
Quotation Estimate Details:
Date Issued: June 12, 2025
Valid Until: July 12, 2025
Optometrist: Dr. Elena M. Vasquez, O.D.
License No.: IL-OD-2019-44782
1. Purpose of This Quotation Estimate
This Quotation Estimate is issued by Lakeview Vision & Optometry Center, a licensed and fully insured optometrist practice located in the heart of Chicago, United States, to provide Mr. Jonathan R. Whitfield with a comprehensive and transparent breakdown of anticipated costs for a full spectrum of optometrist services. This document serves as a formal Quotation Estimate and does not constitute a binding contract until accepted in writing by the client. All pricing reflects current 2025 rates for optometrist professional services as regulated by the Illinois Department of Financial and Professional Regulation and applicable United States federal healthcare guidelines.
2. Scope of Optometrist Services Included
The following optometrist services have been recommended following the initial consultation conducted on June 5, 2025, at our Chicago, United States facility. Each service is performed by a board-certified Optometrist holding a Doctor of Optometry (O.D.) degree and is subject to the standards set forth by the American Optometric Association.
| Item No. | Optometrist Service Description | Quantity | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|
| 01 | Comprehensive Dilated Eye Examination by Optometrist (includes visual acuity testing, refraction, intraocular pressure measurement, and retinal assessment) | 1 | $225.00 | $225.00 |
| 02 | Advanced Optical Coherence Tomography (OCT) Imaging of the Retina and Optic Nerve | 1 | $150.00 | $150.00 |
| 03 | Corneal Topography and Pachymetry Assessment | 1 | $95.00 | $95.00 |
| 04 | Prescription for Bifocal Progressive Lenses (including lens design and dispensing consultation by Optometrist) | 1 pair | $480.00 | $480.00 |
| 05 | Anti-Reflective, Blue-Light Filtering, and Scratch-Resistant Coating (both lenses) | 1 pair | $120.00 | $120.00 |
| 06 | Frame Selection and Fitting (premium acetate frame, in-stock selection from Chicago showroom) | 1 | $210.00 | $210.00 |
| 07 | Follow-Up Fitting and Adjustment Appointment with Optometrist (within 14 days of initial fitting) | 1 | $75.00 | $75.00 |
| 08 | Annual Eye Health Monitoring Plan (two follow-up examinations per year for the next 12 months) | 2 visits | $175.00 | $350.00 |
| 09 | Emergency After-Hours Optometrist Consultation Access (24/7 phone and telehealth line, Chicago metro area) | 12 months | $45.00 | $540.00 |
| Subtotal (USD) | $2,245.00 | |||
| Illinois State Sales Tax (10.25% on frames and coatings) | $33.68 | |||
| TOTAL ESTIMATED COST (USD) | $2,278.68 | |||
3. Insurance and Payment Considerations
This Quotation Estimate has been prepared with the understanding that the client may submit applicable portions to their vision insurance provider (e.g., VSP, EyeMed, Davis Vision, or a United States employer-sponsored plan). The Optometrist at Lakeview Vision & Optometry Center will file all eligible claims directly with the insurer on behalf of the client. Any co-payments, deductibles, or non-covered items will be the sole responsibility of the client. A detailed itemized receipt compliant with United States Internal Revenue Service (IRS) documentation standards will be provided upon payment. Payment may be made via credit card, debit card, Health Savings Account (HSA) card, Flexible Spending Account (FSA) card, or certified check. A 50% deposit is required to secure the appointment and frame reservation; the remaining balance is due at the time of lens dispensing.
4. Terms and Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. After the expiration date, pricing for optometrist services, frames, and lens products may be subject to revision based on supplier costs and market conditions in the Chicago, United States region.
- All optometrist services described herein will be performed by Dr. Elena M. Vasquez, O.D., or a qualified associate Optometrist at the Lakeview Vision & Optometry Center facility in Chicago, Illinois. The client will be notified in advance if a substitute Optometrist is scheduled.
- The total estimated cost of $2,278.68 is an approximation. Final charges may vary by up to 5% depending on the specific lens material selected, frame adjustments required, or additional diagnostic findings identified during the examination that necessitate supplementary optometrist intervention.
- Lens and frame manufacturing lead time is approximately seven (7) to ten (10) business days from the date of the initial fitting appointment. The Optometrist will notify the client upon completion.
- This Quotation Estimate does not include surgical procedures, pharmaceutical dispensing, or emergency hospital referrals. Should the Optometrist identify a condition requiring referral to an ophthalmologist or retina specialist in the Chicago, United States area, a separate estimate will be provided.
- All services are governed by the laws of the State of Illinois and the United States of America. Any disputes arising from this Quotation Estimate shall be resolved through mediation in Cook County, Illinois, prior to litigation.
- The client acknowledges that acceptance of this Quotation Estimate constitutes consent to the treatment plan outlined by the Optometrist and agreement to the practice's standard privacy policies in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
5. Acceptance and Authorization
By signing below, the client acknowledges receipt of this Quotation Estimate for optometrist services in Chicago, United States, and authorizes Lakeview Vision & Optometry Center to proceed with the services and products described herein. The client confirms that all information provided is accurate and that they have had the opportunity to ask the Optometrist any questions regarding the scope, cost, and alternatives to the recommended treatment plan.
Client Signature:
Jonathan R. Whitfield | Date: _______________Optometrist / Authorized Representative:
Dr. Elena M. Vasquez, O.D. | Date: _______________ ⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
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