Quotation Estimate Optometrist in United States Los Angeles –Free Word Template Download with AI
4520 Wilshire Boulevard, Suite 310, Los Angeles, California 90010, United States
Phone: (213) 555-0187 | Email: [email protected] | CA License #OPT-2024-8841
Quotation EstimateQuotation Details
Quotation No.: QTE-2025-0714-LA
Date Issued: July 14, 2025
Valid Until: August 14, 2025 (30 days)
Prepared By: Dr. Margaret Chen, O.D.
Client Information
Client Name: [Client Full Name]
Address: [Client Address], Los Angeles, CA
Phone: [Client Phone Number]
Email: [Client Email Address]
Dear Valued Client,
Thank you for considering Pacific Vision Optometry Center for your comprehensive eye care needs. This Quotation Estimate has been carefully prepared by our licensed Optometrist team to provide you with a transparent and detailed breakdown of all professional services, diagnostic procedures, and corrective products recommended for your visual health. As a premier eye care facility located in the heart of United States Los Angeles, we are committed to delivering world-class optometric care that meets the highest standards of the American Academy of Optometry. Please review this Quotation Estimate thoroughly and do not hesitate to contact our office should you require any clarification regarding the services or pricing outlined below.
The following Quotation Estimate encompasses a full range of optometric services performed by our board-certified Optometrist in our Los Angeles, United States clinic. All pricing reflects current 2025 rates and includes the use of state-of-the-art diagnostic equipment.
| # | Service / Item Description | Quantity | Unit Price (USD) | Total (USD) |
|---|---|---|---|---|
| 1 | Comprehensive Dilated Eye Examination by Licensed Optometrist (includes visual acuity testing, refraction, intraocular pressure measurement, and retinal evaluation) | 1 | $285.00 | $285.00 |
| 2 | Advanced Optical Coherence Tomography (OCT) Scan – Bilateral (detailed cross-sectional imaging of the retina and optic nerve) | 1 | $175.00 | $175.00 |
| 3 | Corneal Topography & Pachymetry (mapping of corneal curvature and thickness for contact lens fitting or surgical evaluation) | 1 | $145.00 | $145.00 |
| 4 | Visual Field Testing (Humphrey Perimetry) – Bilateral (assessment of peripheral vision for glaucoma screening) | 1 | $195.00 | $195.00 |
| 5 | Custom Prescription Eyeglasses – Premium Anti-Reflective Lenses with Blue Light Filter (includes frame selection consultation by Optometrist) | 1 pair | $620.00 | $620.00 |
| 6 | Soft Toric Contact Lenses – 6-Month Supply (includes fitting, trial period, and follow-up adjustment by Optometrist) | 1 box (30 lenses) | $310.00 | $310.00 |
| 7 | Follow-Up Consultation (30-day post-examination review of lens adaptation and visual performance) | 1 | $95.00 | $95.00 |
| 8 | Urgent Same-Day Optometrist Appointment (priority scheduling within 24 hours in Los Angeles, United States) | 1 | $75.00 | $75.00 |
| Subtotal | $2,000.00 |
| California State Sales Tax (8.75% – Los Angeles County) | $175.00 |
| Insurance Adjustment (Estimate – subject to verification) | -$450.00 |
| Estimated Total Due | $1,725.00 |
Terms & Conditions of This Quotation Estimate
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. Pricing is subject to change after the expiration date without prior notice.
- All optometric services described in this Quotation Estimate will be performed by a licensed Optometrist (O.D.) in good standing with the California Board of Optometry, practicing in compliance with all regulations of the United States Los Angeles metropolitan area.
- The estimated insurance adjustment is based on the client's stated coverage plan. Final reimbursement amounts are determined solely by the client's insurance carrier and may differ from the figures presented in this Quotation Estimate.
- Payment is due in full at the time of service unless a pre-arranged payment plan has been approved in writing by our billing department. Accepted payment methods include Visa, Mastercard, American Express, HSA/FSA cards, and personal checks.
- Prescription eyewear and contact lenses ordered through this Quotation Estimate carry a standard manufacturing and delivery time of 7 to 14 business days. Rush processing may be available at an additional 25% surcharge.
- All diagnostic findings and recommendations provided by our Optometrist are for the exclusive use of the named client and may not be transferred or shared without written authorization.
- This Quotation Estimate does not constitute a binding contract. Final charges may be adjusted if additional procedures are deemed medically necessary during the examination at the discretion of the treating Optometrist.
- Pacific Vision Optometry Center complies with all applicable federal and California state healthcare regulations, including HIPAA privacy standards and the Americans with Disabilities Act.
- Any disputes arising from this Quotation Estimate shall be governed by the laws of the State of California, with jurisdiction in the Superior Court of Los Angeles County, United States.
We appreciate the opportunity to serve your vision needs. Our team of experienced Optometrists in Los Angeles, United States is dedicated to ensuring your complete satisfaction with every aspect of your eye care journey. Should you have any questions regarding this Quotation Estimate, please contact our patient services team at (213) 555-0187 or visit our clinic during regular business hours (Monday through Friday, 8:00 AM to 6:00 PM; Saturday, 9:00 AM to 2:00 PM).
Authorized RepresentativeDr. Margaret Chen, O.D. – Lead Optometrist
Pacific Vision Optometry Center
Signature: _________________________
Date: _________________________ Client Acknowledgment
I have reviewed and accept this Quotation Estimate.
Client Name: _________________________
Signature: _________________________
Date: _________________________ ⬇️ Download as DOCX Edit online as DOCX
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