Quotation Estimate Surgeon in Chile Santiago –Free Word Template Download with AI

Quotation Estimate No.: QTE-SGO-2025-04872
Date of Issue: 15 June 2025
Valid Until: 15 July 2025 Client Name: [Patient / Insurance Provider]
RUT / ID: [To be completed]
Contact: [Phone / Email]

This Quotation Estimate is formally issued to provide a comprehensive and transparent breakdown of all costs associated with the professional services of a Surgeon to be rendered in Santiago, Chile. The document serves as a binding financial reference for the client, the attending Surgeon, and any applicable insurance or health-funding entity. All pricing within this Quotation Estimate reflects the current fee schedule of the surgical practice located in Santiago, Chile, and is subject to the terms and conditions outlined herein. The Surgeon named in this Quotation Estimate holds full certification from the Colegio Médico de Chile and is registered with the Superintendencia de Salud de Chile under license number CM-2019-44871.

The Surgeon referenced throughout this Quotation Estimate is Dr. Alejandro Fuentes Riquelme, a board-certified general and laparoscopic surgeon with over eighteen years of clinical practice in Santiago, Chile. The Surgeon has completed advanced fellowships in minimally invasive surgery at the Universidad de Chile and the Pontificia Universidad Católica de Chile. All procedures quoted in this Quotation Estimate will be personally performed or directly supervised by the Surgeon, ensuring the highest standard of surgical care in Santiago, Chile.

Item No.	Description of Service	Surgeon Role	Quantity	Unit Price (CLP)	Subtotal (CLP)
01	Initial Pre-Operative Consultation & Physical Examination	Surgeon (Primary)	1	185,000	185,000
02	Pre-Surgical Diagnostic Workup (Blood Panels, Imaging, ECG)	Surgeon (Ordering)	1	320,000	320,000
03	Laparoscopic Cholecystectomy — Surgical Procedure	Surgeon (Operating)	1	2,450,000	2,450,000
04	Anesthesiology Services (General Anesthesia, Monitoring)	Surgeon (Coordinating)	1	680,000	680,000
05	Operating Room Facility Fee — Santiago, Chile	Surgeon (Requiring)	1	890,000	890,000
06	Post-Operative Hospital Stay (24-Hour Observation)	Surgeon (Overseeing)	1	540,000	540,000
07	Post-Operative Follow-Up Consultation (Day 7)	Surgeon (Primary)	1	120,000	120,000
08	Post-Operative Follow-Up Consultation (Day 30)	Surgeon (Primary)	1	120,000	120,000
09	Prescription Medications & Wound Care Supplies	Surgeon (Prescribing)	1	95,000	95,000
10	Emergency Post-Operative Coverage (30-Day Window)	Surgeon (On-Call)	1	250,000	250,000
TOTAL ESTIMATED COST (CLP)					5,650,000
TOTAL ESTIMATED COST (USD, approx. at 950 CLP/USD)					$5,947.37

The Surgeon named in this Quotation Estimate assumes full clinical responsibility for the surgical procedure, intra-operative decision-making, and post-operative recovery management within the thirty-day coverage window. The Surgeon will conduct all consultations in Santiago, Chile, at the designated clinic facility. In the event that the Surgeon identifies the need for additional procedures not covered in this Quotation Estimate, a supplementary Quotation Estimate will be issued and must be approved in writing by the client prior to any additional intervention. The Surgeon's professional liability is covered under a comprehensive medical malpractice insurance policy held with a Chilean-registered insurer, compliant with the regulations of the Superintendencia de Salud de Chile.

Terms Governing This Quotation Estimate

Payment Schedule: A 40% deposit (CLP 2,260,000) is due upon acceptance of this Quotation Estimate. The remaining 60% (CLP 3,390,000) is payable within five (5) business days following the completion of the surgical procedure.
Accepted Payment Methods: Bank transfer to a Chilean financial institution, credit card (Visa, Mastercard, American Express), or direct billing to the client's ISAPRE or FONASA insurance provider, where applicable.
Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After this period, the Surgeon reserves the right to revise pricing due to changes in facility costs, medication prices, or regulatory adjustments in Santiago, Chile.
Cancellation Policy: Cancellation by the client more than seventy-two (72) hours before the scheduled procedure will result in a 10% administrative fee. Cancellation within seventy-two hours will forfeit the full deposit.
Tax Considerations: All prices listed in this Quotation Estimate are inclusive of the applicable 19% IVA (Impuesto al Valor Agregado) as mandated by the Servicio de Impuestos Internos de Chile.
Dispute Resolution: Any disputes arising from this Quotation Estimate shall be resolved under the jurisdiction of the courts of Santiago, Chile, in accordance with Chilean civil and commercial law.

Note: This Quotation Estimate is a good-faith financial projection and does not constitute a guarantee of a fixed final cost. The Surgeon may encounter unforeseen intra-operative conditions that necessitate additional interventions, extended hospital stays, or supplementary diagnostic procedures. In such cases, the Surgeon will immediately notify the client or the client's authorized representative and issue an amended Quotation Estimate for approval before proceeding. All services described in this Quotation Estimate are to be performed at the Clinica Las Condes facility in Santiago, Chile, unless otherwise agreed in writing.

By signing below, the client acknowledges receipt of this Quotation Estimate, confirms understanding of all terms and conditions, and authorizes the Surgeon to proceed with the outlined surgical services in Santiago, Chile. The client further confirms that all medical history and relevant information has been disclosed to the Surgeon to the best of their knowledge.

Client / Authorized Representative
Name: ______________________________
RUT / ID: ______________________________
Signature: ______________________________
Date: ______________________________ Surgeon — Dr. Alejandro Fuentes Riquelme, M.D.
License No.: CM-2019-44871
Signature: ______________________________
Date: ______________________________ ⬇️ Download as DOCX Edit online as DOCX

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