Quotation Estimate Surgeon in Australia Melbourne –Free Word Template Download with AI
Professional Surgeon Services — Australia Melbourne
Ref: QE-SRG-MEL-2025-04782
Valid for 30 DaysThis Quotation Estimate has been prepared specifically for Mr. David R. Thompson in relation to the provision of specialist Surgeon services at the Melbourne Advanced Surgical Centre, located in the heart of Australia Melbourne. This document outlines the full scope of surgical procedures, associated medical services, and all ancillary costs that will be incurred should the patient proceed with the recommended course of treatment. All pricing within this Quotation Estimate is provided in Australian Dollars (AUD) and reflects the current fee schedule as approved by the Medical Board of Australia and the relevant health insurance frameworks operating within the state of Victoria.
The undersigned Surgeon, Dr. James A. Whitfield (Fellow of the Royal Australasian College of Surgeons), has conducted a comprehensive clinical assessment of the patient's condition. Based on the diagnostic imaging, laboratory results, and physical examination performed at our Melbourne facility, the following surgical intervention is recommended. This Quotation Estimate covers the complete surgical episode, from pre-operative consultation through to post-operative follow-up care, all delivered by a qualified and registered Surgeon operating in compliance with Australian medical regulations.
| Item No. | Description of Service | Quantity | Unit Price (AUD) | Subtotal (AUD) |
|---|---|---|---|---|
| 01 | Pre-operative Surgeon consultation and clinical assessment (Melbourne facility) | 1 | $320.00 | $320.00 |
| 02 | Diagnostic imaging and laboratory blood work (pathology panel) | 1 | $485.00 | $485.00 |
| 03 | Surgeon's professional fee for primary surgical procedure (theatre time approx. 3.5 hours) | 1 | $4,850.00 | $4,850.00 |
| 04 | Assistant Surgeon fee (second operating surgeon in theatre) | 1 | $1,200.00 | $1,200.00 |
| 05 | Anaesthetist professional fee (general anaesthesia, Australia Melbourne standards) | 1 | $1,650.00 | $1,650.00 |
| 06 | Private hospital room and theatre facility charges (Melbourne private hospital, 2-night stay) | 1 | $3,400.00 | $3,400.00 |
| 07 | Post-operative Surgeon review (Day 1, Day 7, and Week 6 follow-up appointments) | 3 | $185.00 | $555.00 |
| 08 | Prescribed post-operative medications and wound care supplies | 1 | $210.00 | $210.00 |
| 09 | Physiotherapy and rehabilitation sessions (6 sessions, Melbourne clinic) | 6 | $145.00 | $870.00 |
| 10 | Contingency allowance for unforeseen intra-operative complications (estimated) | 1 | $1,500.00 | $1,500.00 |
| TOTAL ESTIMATED COST (AUD) | $16,040.00 | |||
Please note that this Quotation Estimate reflects the full private fee structure for Surgeon services in Australia Melbourne. If the patient holds a valid private health insurance policy with a surgical cover tier, a portion of the costs outlined above may be eligible for rebate under the Australian Private Health Insurance Act 2003. The patient is advised to contact their health insurer prior to the procedure to confirm the exact rebate percentage and any excess or gap amounts that may apply. The Melbourne Advanced Surgical Centre will provide all necessary documentation, including the Surgeon's MBS item numbers and hospital pre-authorisation forms, to facilitate the insurance claim process.
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. Beyond this period, fees may be subject to revision in accordance with the current Australian Medical Association fee schedule.
- All Surgeon services described herein will be performed in strict compliance with the National Health and Medical Research Council (NHMRC) guidelines and the standards set by the Australian Commission on Safety and Quality in Health Care (ACSQHC).
- The contingency allowance (Item 10) will only be charged if additional surgical intervention becomes medically necessary during the procedure. The patient will be informed of any such development as soon as it is identified.
- Payment of the full estimated amount is due within fourteen (14) days of the surgical procedure, unless an alternative payment arrangement has been agreed in writing between the patient and the Melbourne Advanced Surgical Centre.
- This Quotation Estimate does not constitute a guarantee of surgical outcome. The Surgeon will exercise all reasonable clinical judgement in the best interest of the patient, consistent with accepted surgical practice in Australia.
- Any cancellation of the scheduled procedure by the patient must be communicated in writing no fewer than seven (7) days prior to the scheduled date. Cancellations within this window may incur a 25% administrative fee on the total Quotation Estimate amount.
- All personal health information collected in connection with this Quotation Estimate and the subsequent surgical treatment will be handled in accordance with the Australian Privacy Act 1988 and the Notifiable Data Breaches scheme.
Dr. James A. Whitfield holds an active registration with the Australian Health Practitioner Regulation Agency (AHPRA) and is a Fellow of the Royal Australasian College of Surgeons (FRACS). He has over twenty-two years of experience performing the recommended procedure and has completed more than 1,400 such operations at hospitals across Australia Melbourne and the broader Victorian region. His professional indemnity insurance is maintained through the Medical Defence Union (MDU) Australia, providing full coverage for all surgical services rendered under this Quotation Estimate.
By signing below, the patient acknowledges that they have received, read, and understood this Quotation Estimate in full. The patient confirms that the Surgeon has explained the nature of the proposed surgical procedure, the associated risks and benefits, and the estimated costs in a manner that the patient finds satisfactory. The patient authorises the Melbourne Advanced Surgical Centre to proceed with the surgical treatment as described in this document, subject to the terms and conditions set out above.
Patient Signature:
Mr. David R. Thompson | Date: _______________
Surgeon / Authorising Practitioner:
Dr. James A. Whitfield, FRACS | Date: _______________
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