Quotation Estimate Surgeon in Israel Tel Aviv –Free Word Template Download with AI
Professional Surgeon Services — Israel Tel Aviv
MEDICAL SERVICES DIVISION
1. Parties InvolvedService Provider (Surgeon)
Dr. Yael Ben-Ami, MD, FACS
Ramat Gan Medical Center, Surgical Department
12 HaYarkon Street, Tel Aviv, Israel 69719
License No.: IL-MED-2003-4471
Tel: +972-3-640-XXXX
Email: [email protected]
Client / Receiving Party
[Client Name / Institution]
[Address Line 1]
[City, Country]
Contact: [Phone Number]
Email: [Email Address]
Tax / VAT ID: [Number]
This Quotation Estimate is issued by Dr. Yael Ben-Ami, a board-certified Surgeon practicing in Israel Tel Aviv, to provide a comprehensive and transparent breakdown of professional surgical services, pre-operative consultations, intra-operative procedures, and post-operative follow-up care. The Surgeon will perform all duties in accordance with the standards set by the Israeli Medical Association and the Ministry of Health, State of Israel. All services referenced in this Quotation Estimate are to be delivered at the Ramat Gan Medical Center facility located in the Tel Aviv metropolitan area, Israel Tel Aviv, or at an alternative approved surgical center as mutually agreed upon by both parties.
3. Itemized Cost Breakdown| # | Service Description | Quantity | Unit Price (USD) | Subtotal (USD) |
|---|---|---|---|---|
| 1 | Initial Pre-Operative Consultation & Physical Assessment by the Surgeon | 1 session | $850.00 | $850.00 |
| 2 | Diagnostic Imaging Review (CT, MRI, Ultrasound) & Surgical Planning | 1 package | $1,200.00 | $1,200.00 |
| 3 | Primary Surgical Procedure (Minimally Invasive / Laparoscopic) — Surgeon Fee | 1 procedure | $8,500.00 | $8,500.00 |
| 4 | Anesthesiologist Coordination & Intra-Operative Monitoring | 1 procedure | $2,400.00 | $2,400.00 |
| 5 | Operating Room Facility Fee (Israel Tel Aviv certified surgical suite) | 1 day | $3,200.00 | $3,200.00 |
| 6 | Post-Operative Hospital Stay & Nursing Care (up to 3 nights) | 3 nights | $950.00 | $2,850.00 |
| 7 | Post-Operative Follow-Up Visits with the Surgeon (3 visits over 6 weeks) | 3 visits | $450.00 | $1,350.00 |
| 8 | Pathology & Laboratory Testing (pre- and post-operative panels) | 1 package | $780.00 | $780.00 |
| 9 | Medical Records Translation & International Certification (English/Hebrew) | 1 set | $320.00 | $320.00 |
| 10 | Emergency Post-Operative Consultation (24/7 availability, first 30 days) | 1 period | $500.00 | $500.00 |
| TOTAL ESTIMATED COST (USD) | $22,950.00 | |||
| VAT (18% — Israel Tax Authority) | $4,131.00 | |||
| GRAND TOTAL (USD) | $27,081.00 | |||
- 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 pricing based on current market rates in Israel Tel Aviv.
- All surgical procedures will be performed by the named Surgeon, Dr. Yael Ben-Ami, or by a duly qualified associate surgeon of equivalent or superior credentials, subject to the client's written approval.
- Payment terms: 40% deposit due upon acceptance of this Quotation Estimate; 40% due 48 hours prior to the scheduled surgical date; 20% due upon discharge from the facility.
- Payments may be made via international wire transfer to the designated account at Bank Leumi, Tel Aviv branch, Israel, or by credit card through the hospital's billing office. All transactions are subject to Israeli financial regulations.
- The Surgeon and the facility comply with all applicable Israeli medical laws, including the Patient's Rights Law (5756-1996) and the Medical Treatment Regulations. Informed consent forms will be provided in both Hebrew and English prior to any procedure.
- This Quotation Estimate does not constitute a guarantee of surgical outcome. The Surgeon will exercise the highest standard of medical care consistent with accepted practice in Israel Tel Aviv and internationally recognized surgical protocols.
- Any additional procedures, complications, or extended hospitalization beyond the scope described herein will be communicated to the client in writing and will be billed separately at the Surgeon's standard rates.
- This Quotation Estimate is non-transferable and is issued exclusively to the client named in Section 1. Any modification requires a written amendment signed by both parties.
- Disputes arising from this Quotation Estimate shall be governed by the laws of the State of Israel, with jurisdiction vested in the competent courts of Tel Aviv, Israel.
By signing below, the client acknowledges receipt of this Quotation Estimate for Surgeon services in Israel Tel Aviv and agrees to the terms, conditions, and pricing outlined herein. The Surgeon confirms availability and commitment to deliver the services as described.
Client / Authorized Representative
Name: _________________________
Date: _________________________
Dr. Yael Ben-Ami, MD, FACS
Surgeon — Ramat Gan Medical Center
Tel Aviv, Israel
Date: _________________________
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