Quotation Estimate Surgeon in Israel Jerusalem –Free Word Template Download with AI
Professional Surgeon Services — Israel Jerusalem
Document Reference: QE-JER-2025-04782 | Status: OFFICIAL
1. Parties InvolvedService Provider (Surgeon)
Name: Dr. Yael Ben-Ami, MD, FACS
Clinic: Jerusalem Medical Center – Surgical Division
Address: 12 HaYehudim Street, Jerusalem 94681, Israel
Phone: +972-2-555-0147
Email: [email protected]
Client / Patient
Name: Mr. David Rosenfeld
ID No.: 004-558-221
Address: 8 King George Street, Jerusalem 94512, Israel
Phone: +972-52-334-8891
Insurance Ref.: Clalit-Med-2025-77812
2. Scope of Services – Surgeon Consultation & ProcedureThis Quotation Estimate is issued by Dr. Yael Ben-Ami, a board-certified Surgeon practicing in Israel Jerusalem, to provide a comprehensive and transparent breakdown of all anticipated costs associated with the planned surgical intervention. The following services are included within the scope of this estimate:
| # | Service Description | Quantity | Unit Price (ILS) | Total (ILS) |
|---|---|---|---|---|
| 1 | Initial Surgeon Consultation & Pre-Operative Assessment (includes physical examination, medical history review, and discussion of surgical options in Jerusalem) | 1 session | ₪ 1,200.00 | ₪ 1,200.00 |
| 2 | Pre-Operative Diagnostic Imaging (CT Scan & Ultrasound) performed at Jerusalem Medical Center radiology department | 1 package | ₪ 3,450.00 | ₪ 3,450.00 |
| 3 | Pre-Operative Laboratory Work (complete blood panel, coagulation profile, cardiac clearance, and anesthetic evaluation) | 1 package | ₪ 1,850.00 | ₪ 1,850.00 |
| 4 | Primary Surgical Procedure – Laparoscopic Cholecystectomy (performed by the Surgeon with a two-person surgical team in an accredited operating theatre in Israel Jerusalem) | 1 procedure | ₪ 18,500.00 | ₪ 18,500.00 |
| 5 | General Anesthesia & Intra-Operative Monitoring (anesthesiologist fees, IV access, pulse oximetry, and post-anesthesia recovery room for 2 hours) | 1 session | ₪ 4,200.00 | ₪ 4,200.00 |
| 6 | Post-Operative Hospital Stay (private single room, nursing care, and medication management) – estimated 2 nights | 2 nights | ₪ 2,800.00 | ₪ 5,600.00 |
| 7 | Post-Operative Surgeon Follow-Up Visits (2 visits within 14 days to assess wound healing, remove sutures, and review pathology results) | 2 visits | ₪ 750.00 | ₪ 1,500.00 |
| 8 | Pathology & Histology Analysis of excised tissue (processed at Jerusalem University Medical Laboratory) | 1 sample | ₪ 1,100.00 | ₪ 1,100.00 |
| 9 | Prescribed Post-Operative Medications (antibiotics, analgesics, and anti-inflammatory agents for 10 days) | 1 course | ₪ 480.00 | ₪ 480.00 |
| 10 | Administrative & Documentation Fees (medical records, insurance claim processing, and official discharge summary in Hebrew and English) | 1 package | ₪ 350.00 | ₪ 350.00 |
| Subtotal (Items 1–10) | ₪ 38,280.00 |
| VAT (18% – Israel Standard Rate) | ₪ 6,890.40 |
| Grand Total (Quotation Estimate Amount) | ₪ 45,170.40 |
- Validity: This Quotation Estimate is valid for thirty (30) calendar days from the date of issue. After the expiration date, all prices are subject to revision based on current hospital tariffs, pharmaceutical pricing, and Surgeon availability in Israel Jerusalem.
- Payment Schedule: A deposit of 30% (₪ 13,551.12) is due upon acceptance of this Quotation Estimate to secure the Surgeon's operating theatre slot. The remaining 70% is payable within seven (7) business days following the completion of the surgical procedure and discharge.
- Insurance Coverage: The client is advised to verify coverage with Clalit Health Services prior to the procedure. This Quotation Estimate reflects full private-pay rates. Any amounts reimbursed by the insurer will be deducted from the final invoice.
- Scope Limitations: This estimate covers the standard surgical pathway as described. Should the Surgeon identify additional pathology or complications intra-operatively that necessitate extended intervention, a supplementary Quotation Estimate will be presented to the client (or their designated medical power of attorney) prior to any additional procedure, wherever clinically feasible.
- Surgeon Availability: The operating date is contingent upon the confirmed availability of Dr. Ben-Ami and the designated operating theatre at Jerusalem Medical Center. Rescheduling due to force majeure or medical necessity will not incur additional fees.
- Confidentiality: All medical information contained within this document and the associated surgical records are protected under the Israeli Privacy Protection Law, 5741-1981, and the Hospital's internal data governance policies.
- Governing Law: This Quotation Estimate and any resulting service agreement shall be governed by and interpreted in accordance with the laws of the State of Israel. Any disputes shall be subject to the exclusive jurisdiction of the courts in Jerusalem.
By signing below, the client acknowledges that this Quotation Estimate has been reviewed, all terms are understood, and the client authorizes the Surgeon and Jerusalem Medical Center to proceed with the outlined surgical services. The client confirms that all relevant medical history has been disclosed and that no contraindications to the proposed procedure are known.
Client Signature
Mr. David Rosenfeld
Date: _______________
Surgeon / Service Provider
Dr. Yael Ben-Ami, MD, FACS
Date: _______________
Witness / Medical Power of Attorney
Name: _______________
Date: _______________
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