Quotation Estimate Surgeon in Iran Tehran –Free Word Template Download with AI
Professional Surgeon Services — Iran Tehran
Medical & Surgical Consultation & Procedure Estimation
1. Parties InvolvedService Provider (Surgeon)
Name: Dr. Amir Hosseini, MD, FACS
Specialty: General & Vascular Surgery
Clinic: Tehran Advanced Surgical Center
Address: Vali-e-Asr Street, District 1, Tehran, Iran
License No.: IRN-MED-2019-88341
Contact: +98 21 8876 5432
Client / Patient
Name: [Patient Full Name]
National ID: [To be confirmed]
Address: Tehran, Iran
Referring Physician: Dr. S. Karimi, Internal Medicine
Contact: [To be confirmed]
2. Scope of Surgeon Services — Iran TehranThis Quotation Estimate outlines the comprehensive surgical services to be provided by the undersigned Surgeon at the Tehran Advanced Surgical Center, located in the heart of Iran Tehran. The scope encompasses pre-operative evaluation, the surgical procedure itself, immediate post-operative care, and follow-up consultations. All services are rendered in accordance with the standards set by the Iranian Ministry of Health and Medical Education and the Tehran University of Medical Sciences guidelines.
The Surgeon will perform a laparoscopic cholecystectomy (gallbladder removal) as indicated by the patient's clinical presentation and imaging results. The procedure will be conducted at the fully equipped operating theatre within the Tehran Advanced Surgical Center, which is situated in the central district of Tehran, Iran, ensuring accessibility for the patient and family members.
3. Itemized Quotation Estimate Breakdown| # | Service / Item Description | Quantity | Unit Price (IRR) | Subtotal (IRR) |
|---|---|---|---|---|
| 1 | Pre-operative consultation with the Surgeon (initial assessment, history, physical examination) | 1 session | 2,500,000 | 2,500,000 |
| 2 | Pre-operative laboratory work (CBC, liver function, coagulation panel, blood typing) | 1 set | 1,800,000 | 1,800,000 |
| 3 | Abdominal ultrasound and CT scan (imaging for surgical planning) | 1 set | 3,200,000 | 3,200,000 |
| 4 | Anesthesiology consultation and general anesthesia administration | 1 procedure | 4,500,000 | 4,500,000 |
| 5 | Laparoscopic cholecystectomy — Surgeon's professional fee (operating time approx. 90 min) | 1 procedure | 18,000,000 | 18,000,000 |
| 6 | Operating theatre facility fee (Tehran Advanced Surgical Center, Iran Tehran) | 1 day | 7,500,000 | 7,500,000 |
| 7 | Surgical instruments, laparoscopic equipment, and disposable supplies | 1 set | 5,200,000 | 5,200,000 |
| 8 | Inpatient hospitalization (24-hour post-operative observation, Tehran facility) | 1 night | 6,000,000 | 6,000,000 |
| 9 | Post-operative medications (analgesics, antibiotics, anti-emetics) | 1 course | 1,200,000 | 1,200,000 |
| 10 | Follow-up consultation with the Surgeon (Day 7 and Day 30 post-op) | 2 sessions | 1,500,000 | 3,000,000 |
| 11 | Pathology examination of excised gallbladder tissue | 1 sample | 2,000,000 | 2,000,000 |
| 12 | Administrative and documentation fees (medical records, discharge summary) | 1 set | 500,000 | 500,000 |
| TOTAL QUOTATION ESTIMATE (IRR) | 62,400,000 | |||
- This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, the Surgeon reserves the right to revise the pricing based on current market conditions in Iran Tehran.
- The total amount stated in this Quotation Estimate covers the services explicitly listed in Section 3. Any additional procedures, complications, or extended hospitalization beyond the estimated 24 hours will be subject to a separate supplementary Quotation Estimate issued by the Surgeon prior to the additional intervention.
- A deposit of 30% of the total Quotation Estimate amount (18,720,000 IRR) is required at the time of scheduling the procedure to secure the operating theatre and the Surgeon's availability at the Tehran facility.
- The remaining 70% balance is due within 48 hours following the completion of the surgical procedure and discharge from the hospital.
- Payment may be made via bank transfer to the Tehran Advanced Surgical Center account, or by approved electronic payment methods registered with the Iranian banking system.
- The Surgeon and the facility are not liable for pre-existing conditions that were not disclosed during the initial consultation. The patient is required to provide a complete medical history.
- All medical records and imaging obtained during the course of treatment in Iran Tehran shall remain the property of the patient and may be requested in writing at any time.
- This Quotation Estimate does not constitute a guarantee of a specific surgical outcome. The Surgeon will exercise the highest standard of care in accordance with the medical ethics code of the Iranian Medical Association.
- In the event of emergency re-intervention within 30 days of the primary procedure, the Surgeon's professional fee for the re-operation shall be waived, with only facility and supply costs applicable.
I, Dr. Amir Hosseini, hereby confirm that this Quotation Estimate accurately reflects the estimated costs for the surgical services to be performed at my practice in Iran Tehran. I am a board-certified Surgeon registered with the Iranian Medical Association and hold active privileges at the Tehran Advanced Surgical Center. I commit to providing the highest standard of surgical care in full compliance with all applicable regulations of the Iranian healthcare system.
Dr. Amir Hosseini, MD, FACS
Surgeon / Service Provider
Date: _______________
Patient / Authorized Representative
Client Acknowledgment
Date: _______________
Tehran Advanced Surgical Center
Administrative Seal & Authorization
Date: _______________
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