Quotation Estimate Physiotherapist in United States Chicago –Free Word Template Download with AI
2150 N. Lake Shore Drive, Suite 400, Chicago, Illinois 60614, United States
Phone: (312) 555-0187 | Email: [email protected]
Illinois License No. 269.001234 | NPI: 1093847562
Quotation EstimatePrepared For (Client)
Name: Mr. James R. Whitfield
Address: 847 W. Superior Street, Apt 12B, Chicago, IL 60614
Phone: (773) 555-0442
Email: [email protected]
Referring Physician: Dr. Angela Torres, MD – Orthopedic Surgery, Northwestern Memorial Hospital
Quotation Details
Quotation Estimate No.: QTE-2025-07342
Date of Issue: June 12, 2025
Valid Until: July 12, 2025 (30 days)
Prepared By: Sarah K. Mitchell, DPT, OCS – Lead Physiotherapist
Service Location: Chicago, Illinois, United States
Dear Mr. Whitfield,
Thank you for contacting Chicago Lakeside Physiotherapy & Rehabilitation Center regarding your post-operative rehabilitation needs. This Quotation Estimate has been carefully prepared by our senior Physiotherapist, Dr. Sarah K. Mitchell, following your initial consultation on June 5, 2025, at our clinic in United States Chicago. The following document outlines the comprehensive physiotherapy program recommended for your recovery following a total knee arthroplasty (TKA) of the left knee, performed on May 28, 2025, at Northwestern Memorial Hospital.
As a licensed and board-certified Physiotherapist operating in the United States Chicago metropolitan area, our team is committed to delivering evidence-based, patient-centered rehabilitation. The program outlined in this Quotation Estimate encompasses a twelve-week structured recovery plan designed to restore full range of motion, muscular strength, gait mechanics, and functional independence. All sessions will be conducted at our state-of-the-art facility on Lake Shore Drive, which is equipped with hydrotherapy pools, isokinetic dynamometers, and advanced manual therapy stations.
| # | Service Description | Frequency | Duration | Unit Rate (USD) | Total (USD) |
|---|---|---|---|---|---|
| 1 | Initial Comprehensive Assessment & Treatment Plan Development by Lead Physiotherapist | One-time | 60 min | $185.00 | $185.00 |
| 2 | Manual Therapy & Joint Mobilization Sessions (Weeks 1–4) | 3x / week | 45 min | $145.00 | $1,740.00 |
| 3 | Therapeutic Exercise & Progressive Strengthening Program (Weeks 5–8) | 3x / week | 45 min | $135.00 | $1,620.00 |
| 4 | Gait Retraining & Functional Mobility Training (Weeks 9–12) | 2x / week | 50 min | $140.00 | $1,120.00 |
| 5 | Hydrotherapy Pool Sessions (Aquatic Rehabilitation) | 1x / week | 40 min | $160.00 | $640.00 |
| 6 | Home Exercise Program Design & Digital Follow-Up (App-based) | 12 weeks | Ongoing | $25.00/mo | $75.00 |
| 7 | Progress Re-evaluation & Discharge Summary (Week 12) | One-time | 45 min | $150.00 | $150.00 |
| 8 | Therapeutic Modalities (Ultrasound, TENS, Cryotherapy, Iontophoresis) | As needed | Per session | $45.00 | $540.00 |
| Subtotal | $6,070.00 | ||||
| Illinois State Sales Tax (10.25%) | $622.18 | ||||
| Grand Total (USD) | $6,692.18 | ||||
Please note that this Quotation Estimate reflects our standard self-pay rates for services rendered by our Physiotherapist team in United States Chicago. We accept most major insurance carriers including Aetna, Blue Cross Blue Shield of Illinois, Cigna, UnitedHealthcare, and Humana. If you wish to apply your insurance benefits, our billing department will submit a pre-authorization request on your behalf. The final out-of-pocket amount may vary depending on your deductible, co-pay structure, and annual out-of-pocket maximum. We strongly recommend contacting your insurance provider prior to commencing treatment to confirm coverage details.
Payment options include: full payment at the time of service, bi-weekly installments, or a 0% interest financing plan over 12 months through our partnered provider, CareCredit. A 20% deposit is required to secure your initial appointment slot.
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, rates may be subject to revision based on current market conditions in the United States Chicago healthcare sector.
- All physiotherapy sessions must be scheduled at least 48 hours in advance. Cancellations made less than 24 hours prior to an appointment will incur a 50% fee of the session rate.
- The Physiotherapist reserves the right to modify the treatment plan based on the patient's clinical progress, physician recommendations, or any changes in medical condition.
- Patients are required to wear appropriate athletic attire and closed-toe footwear during all in-clinic sessions.
- Our facility operates in compliance with all Illinois Department of Public Health regulations, HIPAA privacy standards, and the Joint Commission accreditation requirements applicable to outpatient rehabilitation centers in the United States Chicago region.
- Any disputes arising from this Quotation Estimate shall be governed by the laws of the State of Illinois and resolved in the Circuit Court of Cook County, Chicago, Illinois.
- Photographic documentation of progress may be taken with written patient consent for clinical and educational purposes only.
By signing below, the client acknowledges receipt of this Quotation Estimate, agrees to the terms and conditions outlined herein, and authorizes the Physiotherapist team at Chicago Lakeside Physiotherapy & Rehabilitation Center to commence the described treatment program in United States Chicago.
Client SignatureName: James R. Whitfield
Date: ______________________ Physiotherapist / Authorized Representative
Name: Sarah K. Mitchell, DPT, OCS
Date: ______________________ ⬇️ Download as DOCX Edit online as DOCX
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