Quotation Estimate Optometrist in United States Houston –Free Word Template Download with AI
Bayou City Vision & Optometry Center
4820 Westheimer Road, Suite 310, Houston, Texas 77056, United States
Phone: (713) 555-0142 | Email: [email protected]
Licensed Optometrist – Texas Board of Optometry #TX-48291 Quotation Estimate No.: QTE-2025-HOU-0387Date of Issue: June 12, 2025
Valid Until: July 12, 2025 Prepared For:
Mr. Jonathan R. Whitfield
2214 Memorial Drive, Apt 5B
Houston, Texas 77007, United States
Phone: (281) 555-7734
Dear Mr. Whitfield,
Thank you for contacting Bayou City Vision & Optometry Center regarding your comprehensive optometry needs. As a board-certified Optometrist practicing in the greater Houston, United States area for over fifteen years, I am pleased to provide you with this detailed Quotation Estimate outlining the full scope of services, associated costs, and recommended treatment plan tailored specifically to your visual health requirements. This Quotation Estimate reflects current 2025 pricing for all optometric procedures performed at our Houston clinic and is structured to ensure complete transparency for your financial planning.
Scope of Optometrist Services – Quotation Estimate Line Items
| # | Service Description | Optometrist Procedure | Qty | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 1 | Comprehensive Dilated Eye Examination | Full Optometrist assessment including visual acuity, refraction, and retinal evaluation | 1 | $285.00 | $285.00 |
| 2 | Corneal Topography & Pachymetry | Optometrist-guided corneal mapping for contact lens fitting or pre-surgical evaluation | 1 | $175.00 | $175.00 |
| 3 | Glaucoma Screening (OCT + Visual Field) | Optometrist-administered optical coherence tomography and perimetry testing | 1 | $220.00 | $220.00 |
| 4 | Macular Function & Color Vision Testing | Optometrist evaluation of central vision, Amsler grid, and Ishihara plates | 1 | $95.00 | $95.00 |
| 5 | Prescription Eyeglasses – Bifocal Lenses (Premium) | Optometrist-dispensed progressive bifocal lenses, anti-reflective coating, scratch-resistant, in acetate frame | 1 pair | $640.00 | $640.00 |
| 6 | Soft Toric Contact Lenses (Monthly) | Optometrist-fitted monthly disposable toric contacts, 6-pack | 2 | $185.00 | $370.00 |
| 7 | Follow-Up Contact Lens Fitting Visit | Optometrist re-evaluation at 7-day and 30-day intervals for lens adaptation | 2 | $75.00 | $150.00 |
| 8 | Annual Optometrist Monitoring Plan (12 months) | Scheduled Optometrist check-ups, blood pressure screening, and retinal photography in Houston clinic | 1 | $320.00 | $320.00 |
| Subtotal | $2,255.00 |
| Applicable Texas Sales Tax (8.25%) | $185.99 |
| Insurance Adjustment (Vision FSA – estimated) | -$250.00 |
| Grand Total Due (USD) | $2,190.99 |
Quotation Estimate Terms & Conditions
1. Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. Pricing is subject to change after the expiration date due to fluctuations in lens manufacturing costs and optometric supply chain adjustments within the Houston, United States market.
2. Payment Schedule: A deposit of 50% ($1,095.50) is due upon acceptance of this Quotation Estimate. The remaining balance is payable at the time of lens dispensing or final Optometrist service delivery. We accept all major credit cards, HSA/FSA cards, and personal checks.
3. Insurance & Reimbursement: Our Optometrist office in Houston participates with major vision insurance carriers including VSP, EyeMed, Davis Vision, and Spectera. The insurance adjustment listed above is an estimate only; final reimbursement amounts are determined by your specific plan. You are responsible for any co-payments, deductibles, or non-covered services.
4. Cancellation & Rescheduling: Appointments for Optometrist services may be rescheduled with a minimum of 48 hours' notice. Cancellations within 48 hours of a scheduled appointment will incur a $50 administrative fee. Unused services from the Annual Optometrist Monitoring Plan may be rescheduled within the 12-month period but are non-refundable.
5. Warranty: All prescription eyeglasses and contact lenses dispensed by our Optometrist carry a 12-month manufacturer warranty against defects in materials and workmanship. This warranty does not cover damage from misuse, loss, or normal wear.
6. Regulatory Compliance: All optometric services described in this Quotation Estimate are performed in full compliance with the Texas Occupations Code, Chapter 401 (Optometry) and the regulations set forth by the Texas Board of Optometry. Our Houston, United States facility is fully licensed and inspected annually.
7. Acceptance: By signing below, you acknowledge that you have reviewed this Quotation Estimate, understand the scope of Optometrist services to be provided, and authorize Bayou City Vision & Optometry Center to proceed with the outlined treatment plan and associated charges.
Prepared by:
Dr. Elena M. Vasquez, O.D., F.A.A.O.
Lead Optometrist, Bayou City Vision & Optometry Center
License No. TX-48291 | NPI: 1497558203
Signature & DateAccepted by Client:
Mr. Jonathan R. Whitfield
Houston, Texas, United States
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