Quotation Estimate Psychiatrist in Russia Saint Petersburg –Free Word Template Download with AI

Quotation Estimate No.:	QTE-SPB-2025-04871
Date of Issue:	14 June 2025
Valid Until:	14 July 2025 (30 calendar days)
Prepared By:	Dr. Elena V. Sokolova, Chief Psychiatrist, MD, PhD
Client / Patient Name:	Mr. Alexander D. Petrov
Client Address:	12 Nevsky Prospekt, Apt. 47, Saint Petersburg, 191025, Russia
Referral Source:	General Practitioner, Polyclinic No. 3, Saint Petersburg
Service Location:	NeuroPsychiatric Care Center, 5 Liteyny Avenue, Saint Petersburg, 191011, Russia

This Quotation Estimate is issued by the NeuroPsychiatric Care Center, a licensed psychiatric and psychotherapeutic facility operating in Russia Saint Petersburg, to provide Mr. Alexander D. Petrov with a comprehensive, itemized breakdown of all anticipated costs associated with a full course of Psychiatrist-led diagnostic and therapeutic services. This document serves as a formal financial proposal and does not constitute a binding contract until both parties have executed the accompanying Service Agreement. All pricing in this Quotation Estimate is denominated in Russian Rubles (RUB) and reflects the current fee schedule effective as of the date of issue.

The following Psychiatrist services have been recommended following the initial referral and preliminary assessment conducted at our Saint Petersburg clinic. Each service is performed or supervised by a board-certified Psychiatrist registered with the Ministry of Health of the Russian Federation. The scope of care is designed to address the patient's diagnosed condition of Generalized Anxiety Disorder with comorbid mild depressive episode, as documented in the referral letter dated 2 June 2025.

#	Service Description	Frequency / Duration	Unit Price (RUB)	Quantity	Subtotal (RUB)
1	Initial Psychiatrist Consultation & Comprehensive Psychiatric Assessment (including medical history review, mental status examination, and diagnostic interview)	1 session / 90 min	8,500	1	8,500
2	Follow-up Psychiatrist Consultation (progress review, medication adjustment, therapeutic plan revision)	Weekly / 45 min	5,200	12	62,400
3	Cognitive-Behavioral Therapy (CBT) Sessions conducted under Psychiatrist supervision	Bi-weekly / 60 min	4,800	6	28,800
4	Psychological Testing & Psychometric Battery (Beck Depression Inventory, GAD-7, MMSE, neuropsychological screening)	1 session / 120 min	12,000	1	12,000
5	Prescription Medication Management (SSRI initiation, titration, and 12-week supply of Sertraline 50 mg)	12 weeks supply	3,200	1	3,200
6	Psychiatric Discharge Summary & Final Assessment Report (detailed clinical documentation for GP referral)	1 session / 60 min	6,500	1	6,500
7	Emergency Psychiatrist Hotline Access (24/7 telephone consultation line, included in package)	12 months	1,500	1	1,500
TOTAL ESTIMATED COST					122,900
VAT (20%)					24,580
GRAND TOTAL (RUB)					147,480

Validity: This Quotation Estimate remains valid for thirty (30) calendar days from the date of issue. After the expiration date, all prices are subject to revision based on the current fee schedule of the NeuroPsychiatric Care Center in Russia Saint Petersburg.
Payment Schedule: The initial Psychiatrist consultation fee (Item 1) is due at the time of the first appointment. The remaining balance shall be payable in three equal monthly installments of RUB 45,826.67, due on the 1st of each month. Late payments shall incur a penalty of 1.5% per month.
Payment Methods: Payment may be made via bank transfer to the clinic's account at Sberbank, Saint Petersburg branch, or by cash/card at the clinic reception. International wire transfers are accepted with an additional 2% processing surcharge.
Cancellations: Appointments must be cancelled at least 24 hours in advance. Cancellations made within 24 hours or no-shows will be charged 50% of the session fee. The Psychiatrist reserves the right to reschedule due to medical emergencies without penalty to the patient.
Confidentiality: All patient records, diagnostic results, and treatment plans are protected under Federal Law No. 323-FZ "On the Fundamentals of Health Protection of Citizens in the Russian Federation" and the clinic's internal data protection policy. No information will be disclosed without written patient consent.
Scope Limitations: This Quotation Estimate covers outpatient Psychiatrist services only. Inpatient psychiatric hospitalization, emergency psychiatric intervention, or services requiring referral to a specialized federal psychiatric hospital in Saint Petersburg are not included and will be quoted separately.
Medication Disclaimer: Prescription medications listed in this Quotation Estimate are subject to availability and may be substituted with therapeutically equivalent alternatives at the Psychiatrist's discretion. No additional charge applies for equivalent substitutions.
Governing Law: This Quotation Estimate and any resulting Service Agreement shall be governed by and interpreted in accordance with the civil and healthcare legislation of the Russian Federation, with jurisdiction vested in the courts of Saint Petersburg.

By signing below, the patient (or legal guardian) acknowledges receipt of this Quotation Estimate for Psychiatrist services in Russia Saint Petersburg, confirms understanding of the scope of services, associated costs, and terms outlined herein, and authorizes the NeuroPsychiatric Care Center to proceed with the recommended treatment plan upon execution of the formal Service Agreement.

Patient / Legal Guardian:

Name: ______________________________

Signature: ______________________________

Date: ______________________________

Authorized Representative, NeuroPsychiatric Care Center:

Name: Dr. Elena V. Sokolova

Signature: ______________________________

Date: ______________________________

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