Quotation Estimate Optometrist in United States Miami –Free Word Template Download with AI
1200 Biscayne Boulevard, Suite 450, Miami, Florida 33132, United States
Phone: (305) 555-0187 | Email: [email protected]
Florida Board of Optometry License No. FL-OP-2024-08841
Quotation EstimateQuotation Details
Quotation No.: QTE-MIA-2025-0472
Date Issued: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Prepared By: Dr. Elena Vasquez, O.D.
Service Location: Miami, Florida, United States
Client Information
Name: [Client Full Name]
Address: [Client Address], Miami, FL 33101
Phone: (305) 555-XXXX
Email: [[email protected]]
Insurance Provider: [Provider Name / N/A]
This Quotation Estimate is issued by Miami Vision Care Optometry Center, a licensed and fully accredited Optometrist practice operating in the city of Miami, United States. This document provides a comprehensive and itemized breakdown of all professional optometric services, diagnostic procedures, corrective lens prescriptions, and associated materials that will be provided to the client. All pricing reflects current 2025 rates applicable to the Miami metropolitan area and complies with the regulations set forth by the Florida Board of Optometry and the Florida Department of Health. This Quotation Estimate is a good-faith projection of costs and does not constitute a binding contract until formally accepted in writing by both parties.
| Item No. | Description of Optometrist Service | Qty | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|
| 01 | Comprehensive Dilated Eye Examination by Licensed Optometrist (includes visual acuity testing, refraction, intraocular pressure measurement, retinal evaluation, and binocular vision assessment) | 1 | $225.00 | $225.00 |
| 02 | Corneal Topography and Pachymetry (advanced diagnostic imaging of corneal curvature and thickness for contact lens fitting or pre-surgical evaluation) | 1 | $150.00 | $150.00 |
| 03 | Optical Coherence Tomography (OCT) of the Macula and Retinal Nerve Fiber Layer (non-invasive cross-sectional imaging for early detection of glaucoma, macular degeneration, and diabetic retinopathy) | 1 | $175.00 | $175.00 |
| 04 | Prescription Bifocal / Progressive Addition Lenses (premium aspheric, anti-reflective, blue-light filtering coating, 1.67 high-index material, per pair) | 1 | $485.00 | $485.00 |
| 05 | Acetate Designer Frame (Italian-made, UV400 protection, includes nose pads and temple tips) | 1 | $210.00 | $210.00 |
| 06 | Soft Toric Contact Lens Fitting and Trial (includes initial fitting session, one follow-up adjustment visit, and one pair of trial lenses) | 1 | $195.00 | $195.00 |
| 07 | Prescription Soft Toric Contact Lenses (30-day disposable, box of 30 lenses, per eye) | 2 | $145.00 | $290.00 |
| 08 | Annual Follow-Up Vision Check (refraction update, lens wear assessment, and general ocular health screening) | 1 | $95.00 | $95.00 |
| 09 | Written Prescription and Referral Documentation (for ophthalmologist referral if indicated, insurance pre-authorization forms, and digital records transfer) | 1 | $0.00 | $0.00 |
| Subtotal | $1,830.00 |
| Florida State Sales Tax (6.5% – Miami-Dade County) | $118.95 |
| Local Surcharge (Miami-Dade County, 0.5%) | $9.15 |
| Estimated Insurance Adjustment (if applicable) | -$320.00 |
| Estimated Total Due (USD) | $1,638.10 |
The Optometrist services outlined in this Quotation Estimate are delivered at our fully equipped clinic located in downtown Miami, United States. Our practice is staffed by board-certified optometrists who adhere to the highest standards of clinical care as mandated by the Florida Board of Optometry. All diagnostic equipment, including the OCT scanner, corneal topographer, and phoropter, is calibrated and maintained in accordance with FDA guidelines. The Optometrist team at Miami Vision Care Optometry Center provides personalized care tailored to the diverse visual needs of the Miami community, including bilingual (English/Spanish) patient consultations. This Quotation Estimate covers all services listed above for a single patient and a single treatment cycle. Any additional procedures identified during the examination that fall outside this scope will be communicated to the client prior to implementation and will require a separate written authorization.
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, pricing may be subject to revision based on supplier costs, insurance plan changes, or regulatory updates in the state of Florida.
- Payment Terms: Full payment is due at the time of service unless a pre-arranged payment plan is agreed upon in writing. Accepted payment methods include major credit cards (Visa, Mastercard, American Express), debit cards, HSA/FSA cards, and personal checks. A 2.5% convenience fee applies to credit card transactions exceeding $500.00.
- Insurance: The estimated insurance adjustment shown in this Quotation Estimate is based on the client's current plan benefits as of the date of issue. The client is responsible for any co-pays, deductibles, or out-of-network charges not covered by the insurance provider. Miami Vision Care Optometry Center is in-network with major carriers operating in the United States, including Aetna, Cigna, UnitedHealthcare, and Blue Cross Blue Shield of Florida.
- Cancellations and Rescheduling: Appointments must be rescheduled or cancelled at least 24 hours in advance. Late cancellations or no-shows will be subject to a 50% fee of the scheduled Optometrist consultation charge.
- Warranty: Prescription lenses and frames carry a 12-month manufacturer warranty against defects in materials and workmanship. The warranty does not cover damage from misuse, accidents, or normal wear. Contact lens fittings include a 30-day adaptation guarantee.
- Confidentiality: All patient records, diagnostic images, and prescription data are maintained in strict compliance with the Health Insurance Portability and Accountability Act (HIPAA) and Florida state privacy statutes. This Quotation Estimate and all associated documents are treated as confidential medical records.
- Regulatory Compliance: All services are performed in accordance with the Florida Statutes Chapter 458 (Optometry), the Florida Administrative Code, and applicable federal regulations of the United States Food and Drug Administration (FDA) regarding prescription eyewear and contact lenses.
- Acceptance: This Quotation Estimate becomes a binding agreement upon the client's written signature and the Optometrist practice's countersignature. No services will be rendered until this document is fully executed by both parties.
By signing below, the client acknowledges that they have reviewed this Quotation Estimate in its entirety, understand the scope of Optometrist services to be provided in Miami, United States, and agree to the terms, conditions, and estimated costs outlined herein. The client further authorizes Miami Vision Care Optometry Center to submit claims to the designated insurance provider and to perform the listed procedures as described.
Client Signature: ___________________________
Printed Name: ___________________________
Date: ___________________________
Optometrist / Authorized Representative: ___________________________
Printed Name: Dr. Elena Vasquez, O.D.
Date: ___________________________
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