Quotation Estimate Physiotherapist in Belgium Brussels –Free Word Template Download with AI

Quotation Estimate

Quotation Details

Quotation No: QE-2025-0487

Date Issued: 14 June 2025

Valid Until: 14 July 2025

Prepared For: Mr. Jean-Pierre Van den Berghe

Address: 8 Rue de la Loi, 1040 Brussels, Belgium

Service Provider

Physiotherapist: Dr. Sophie Lemaire, DPT

Specialisation: Orthopaedic & Sports Rehabilitation

Registration: Belgian Physiotherapist Register No. PT-2019-08834

Clinic: Brussels Physiotherapy & Rehabilitation Centre

Location: Belgium Brussels, Ixelles District

Dear Mr. Van den Berghe,

Thank you for contacting our clinic regarding your rehabilitation needs. This Quotation Estimate has been carefully prepared by our senior Physiotherapist, Dr. Sophie Lemaire, following your initial consultation on 10 June 2025 at our facility in Belgium Brussels. The purpose of this document is to provide you with a comprehensive and transparent breakdown of the physiotherapy services, estimated costs, and associated conditions for your ongoing treatment programme. Please review this Quotation Estimate thoroughly and do not hesitate to contact our administrative team should you require any clarification or adjustments before authorising the commencement of treatment.

Scope of Physiotherapy Services

Based on the clinical assessment conducted by our Physiotherapist, the following treatment plan has been designed to address your post-operative knee rehabilitation and associated muscular imbalances. All sessions will take place at our fully equipped clinic located in the heart of Belgium Brussels, where you will benefit from state-of-the-art therapeutic equipment, a dedicated hydrotherapy pool, and a personalised exercise programme tailored to your specific recovery milestones.

#	Service Description	Frequency	Duration	Unit Price (EUR)	Total (EUR)
1	Initial Comprehensive Assessment & Treatment Plan by Lead Physiotherapist	One-time	60 min	120.00	120.00
2	Manual Therapy & Joint Mobilisation Sessions (Knee & Hip)	2x / week	45 min	85.00	1,700.00
3	Therapeutic Exercise & Strengthening Programme	2x / week	45 min	75.00	1,500.00
4	Hydrotherapy / Aquatic Rehabilitation Sessions	1x / week	50 min	95.00	950.00
5	Electrotherapy & Ultrasound Treatment (Pain Management)	1x / week	30 min	55.00	550.00
6	Progress Review & Treatment Plan Adjustment (Monthly)	1x / month	30 min	60.00	240.00
7	Home Exercise Programme & Patient Education Materials	One-time	—	45.00	45.00
8	Final Discharge Assessment & Referral Report to GP	One-time	45 min	90.00	90.00
TOTAL ESTIMATED COST (12-week programme)					5,195.00

Payment Terms & Conditions

1. Validity of Quotation: This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. Should the validity period expire, our Physiotherapist team will re-evaluate the treatment plan and issue a revised Quotation Estimate reflecting any changes in service availability or pricing structures applicable in Belgium Brussels.

2. Payment Schedule: The total estimated amount of EUR 5,195.00 shall be payable in four (4) equal monthly instalments of EUR 1,298.75. The first instalment is due upon signing this Quotation Estimate and commencing treatment. Subsequent payments are due on the first business day of each following month. Payment may be made via bank transfer to our account at BNP Paribas Fortis (IBAN: BE71 0000 0000 0000) or by credit card at the clinic reception.

3. Insurance & Reimbursement: Please note that this Quotation Estimate reflects the full private rate. In Belgium Brussels, a portion of physiotherapy fees may be reimbursed by your mutualité (health insurance fund) or supplementary insurance. Our Physiotherapist will provide you with the appropriate medical invoices (factures médicales) bearing the correct RIZIV/INAMI codes to facilitate your reimbursement claims. We recommend confirming your coverage level with your mutualité prior to the start of treatment.

4. Cancellation Policy: Appointments must be cancelled at least 24 hours in advance. Late cancellations or no-shows will be charged at 50% of the session fee. This policy ensures that our Physiotherapist team can optimise their schedules and maintain the quality of care for all patients in our Belgium Brussels clinic.

5. Treatment Duration: The 12-week programme outlined in this Quotation Estimate is an estimate based on standard recovery timelines. Your treating Physiotherapist will conduct monthly progress reviews and may recommend extending or shortening the programme. Any additional sessions beyond the 12-week period will be billed at the per-session rates specified in this document and will require a supplementary written authorisation.

6. Confidentiality & Data Protection: All patient records, treatment notes, and personal data are handled in strict accordance with the Belgian Data Protection Act and the European General Data Protection Regulation (GDPR). Your medical information will be stored securely at our Belgium Brussels facility and will not be disclosed to third parties without your explicit written consent.

7. Governing Law: This Quotation Estimate and all associated services are governed by the laws of the Kingdom of Belgium. Any disputes arising from this agreement shall be subject to the exclusive jurisdiction of the competent courts in Brussels, Belgium.

Acceptance & Authorisation

By signing below, the client acknowledges that they have read, understood, and accepted all terms and conditions set forth in this Quotation Estimate. The client authorises the Physiotherapist and the Brussels Physiotherapy & Rehabilitation Centre to commence the treatment programme as described herein.

Client Signature
Mr. Jean-Pierre Van den Berghe
Date: ______________________ Physiotherapist / Clinic Representative
Dr. Sophie Lemaire, DPT
Brussels Physiotherapy & Rehabilitation Centre
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX

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