Quotation Estimate Surgeon in Belgium Brussels –Free Word Template Download with AI
12 Avenue Louise, 1050 Brussels, Belgium
Tel: +32 2 555 0142 | Email: [email protected]
VAT No: BE 0123.456.789
Quotation EstimateQuotation Details
Quotation No: QTE-2025-BRU-0487
Date Issued: 15 June 2025
Valid Until: 15 July 2025
Prepared For: Client / Patient Representative
Service Provider
Specialist: Dr. Marc Van den Berghe, MD, FACS
Specialty: General & Minimally Invasive Surgery
Location: Belgium Brussels – Clinique Saint-Luc
Registration: Belgian Medical Council Reg. No. 2019-4471
Important Notice: This Quotation Estimate is a non-binding estimate of costs for the planned surgical procedure. Final billing may vary depending on the complexity of the operation, additional intra-operative findings, and the length of hospitalisation. All prices are quoted in EUR (€) and are subject to Belgian VAT regulations applicable in Belgium Brussels. Description of Surgical ServicesThis Quotation Estimate has been prepared for a Surgeon consultation and operative procedure to be performed at the Brussels Medical Surgical Centre, located in the heart of Belgium Brussels. The Surgeon, Dr. Van den Berghe, is a board-certified specialist with over eighteen years of experience in general and laparoscopic surgery, registered and practising under the regulatory framework of the Belgian Federal Government. The following itemised costs reflect the full scope of the planned intervention, including pre-operative assessment, the surgical procedure itself, anaesthesia, post-operative care, and follow-up appointments within the Belgium Brussels metropolitan area.
Itemised Cost Breakdown| Ref | Service Description | Quantity | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|
| 01 | Initial Surgeon consultation and clinical assessment (Belgium Brussels clinic) | 1 | 185.00 | 185.00 |
| 02 | Pre-operative diagnostic workup (blood panels, imaging, ECG) | 1 | 420.00 | 420.00 |
| 03 | Surgeon operative fee – primary surgical procedure | 1 | 2,850.00 | 2,850.00 |
| 04 | Assistant Surgeon fee (second operating surgeon) | 1 | 950.00 | 950.00 |
| 05 | Anaesthesiologist fee (general anaesthesia, intra-operative monitoring) | 1 | 780.00 | 780.00 |
| 06 | Operating theatre and equipment usage (Belgium Brussels facility) | 1 | 1,200.00 | 1,200.00 |
| 07 | Inpatient hospitalisation – standard room (estimated 3 nights) | 3 | 310.00 | 930.00 |
| 08 | Post-operative Surgeon follow-up visits (2 sessions within 6 weeks) | 2 | 120.00 | 240.00 |
| 09 | Pharmaceuticals, dressings, and consumables | 1 | 340.00 | 340.00 |
| 10 | Pathology and histology analysis (if tissue samples are taken) | 1 | 275.00 | 275.00 |
| Subtotal (excl. VAT) | 8,170.00 | |||
| Belgian VAT (21%) | 1,715.70 | |||
| Grand Total (incl. VAT) | 9,885.70 | |||
1. This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiry date, the Surgeon and the facility in Belgium Brussels reserve the right to revise pricing based on current Belgian healthcare cost indices.
2. A deposit of 30% of the total estimated amount (€2,965.71) is required to confirm the surgical date and reserve the operating theatre. The remaining balance is due within fourteen (14) days following the completion of the procedure.
3. The Surgeon will provide a detailed written post-operative report within five (5) business days. All medical records are maintained in compliance with Belgian data protection legislation (GDPR) and the Belgian Federal Privacy Commission guidelines.
4. In the event of additional intra-operative procedures deemed medically necessary by the Surgeon, the patient or their authorised representative will be informed as soon as practicable. Any additional costs will be itemised in a supplementary Quotation Estimate and require written consent before proceeding.
5. This Quotation Estimate does not constitute a guarantee of surgical outcome. The Surgeon will exercise the highest standard of care in accordance with Belgian medical ethics and the professional code of the Belgian Medical Association.
6. All services are subject to the general terms of the Brussels Medical Surgical Centre, available upon request at the Belgium Brussels reception office.
7. Disputes arising from this Quotation Estimate shall be governed by the civil law of Belgium and shall be submitted to the competent courts of Brussels, Belgium.
Payment DetailsBank: BNP Paribas Fortis, Belgium
IBAN: BE68 5390 0754 7034
BIC/SWIFT: GEBABEBB
Reference: QTE-2025-BRU-0487
Accepted payment methods: Bank transfer, credit card (Visa, Mastercard), and direct debit. All transactions are processed within Belgium Brussels under applicable Belgian financial regulations.
For Brussels Medical Surgical CentreDr. Marc Van den Berghe, MD, FACS
Lead Surgeon – Belgium Brussels
Date: _______________ Client / Patient Representative
Name: _________________________
Signature: _________________________
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
Create your own Word template with our GoGPT AI prompt:
GoGPT