Quotation Estimate Surgeon in Italy Rome –Free Word Template Download with AI
Professional Surgeon Services — Italy Rome
Document Ref: QE-2025-ROME-0847 | Issued by: Clinica San Pietro di Roma S.r.l.
| Quotation Estimate No. | QE-2025-ROME-0847 | Date of Issue | 14 June 2025 |
| Valid Until | 14 September 2025 (90 days) | Currency | Euro (EUR) |
| Prepared For | Dr. Elena Marchetti — Private Patient, Via del Corso 112, 00186 Rome, Italy | Prepared By | Prof. Marco De Santis, Chief of Surgery, Clinica San Pietro di Roma |
| Location of Service | Clinica San Pietro di Roma, Viale della Lungara 210, 00165 Rome, Italy (Italy Rome) | ||
This Quotation Estimate has been prepared in accordance with the professional standards governing medical billing in Italy Rome. It provides a comprehensive, itemized breakdown of all anticipated costs associated with the surgical intervention to be performed by a qualified Surgeon at our facility located in the heart of Italy Rome. The purpose of this document is to ensure full transparency for the patient and to comply with the regulatory requirements set forth by the Italian Ministry of Health and the regional health authority of Lazio. All figures presented in this Quotation Estimate are estimates based on the current clinical assessment and may be subject to minor adjustments should the surgical procedure require modifications intraoperatively.
The primary Surgeon assigned to this case is Prof. Marco De Santis, a board-certified general and vascular surgeon with over twenty-two years of clinical practice in Italy Rome. He holds a full license issued by the Ordine dei Medici Chirurghi e Odontoiatri di Roma and is a member of the Italian Society of Surgery (SIC). The surgical team will additionally include a certified anesthesiologist, two operating room nurses, a surgical assistant, and a post-operative recovery nurse. All members of the team are registered and accredited for practice within the Lazio region of Italy.
| Ref | Service / Item Description | Quantity | Unit Price (EUR) | Subtotal (EUR) |
|---|---|---|---|---|
| 01 | Pre-operative consultation and clinical assessment by the Surgeon (includes history, physical examination, and surgical planning) | 1 session | € 350.00 | € 350.00 |
| 02 | Pre-operative diagnostic workup (blood panels, ECG, chest X-ray, abdominal ultrasound, and anesthetic evaluation) | 1 package | € 620.00 | € 620.00 |
| 03 | Surgical procedure — Laparoscopic cholecystectomy performed by the Surgeon (includes operative time, surgical instruments, and disposable implants) | 1 procedure | € 4,800.00 | € 4,800.00 |
| 04 | Anesthesia services (general anesthesia, intra-operative monitoring, and anesthesiologist fees) | 1 procedure | € 1,200.00 | € 1,200.00 |
| 05 | Operating room facility fee (theatre rental, sterilization, nursing staff, and equipment usage in Italy Rome) | 1 day | € 1,500.00 | € 1,500.00 |
| 06 | Post-operative hospitalization — inpatient stay (2 nights, including room, meals, nursing care, and daily Surgeon rounds) | 2 nights | € 950.00 | € 1,900.00 |
| 07 | Post-operative follow-up consultations by the Surgeon (2 visits within 30 days of discharge) | 2 visits | € 200.00 | € 400.00 |
| 08 | Pharmacological support (post-operative analgesics, antibiotics, and anti-inflammatory medication) | 1 course | € 180.00 | € 180.00 |
| 09 | Pathological examination of excised tissue (histological analysis and written report) | 1 sample | € 320.00 | € 320.00 |
| 10 | Administrative and documentation fees (medical records, discharge summary, and regulatory filings for Italy Rome) | 1 package | € 150.00 | € 150.00 |
| TOTAL ESTIMATED COST (before VAT) | € 11,420.00 | |||
| VAT (22% — Italian standard rate) | € 2,512.40 | |||
| GRAND TOTAL (Quotation Estimate) | € 13,932.40 | |||
- Validity: This Quotation Estimate is valid for a period of ninety (90) calendar days from the date of issue. After this period, all prices are subject to revision based on current market conditions in Italy Rome and any changes in regulatory tariffs.
- Payment Schedule: A deposit of 30% (€ 4,179.72) is due upon acceptance of this Quotation Estimate. The remaining 70% (€ 9,752.68) shall be settled within fifteen (15) business days following the patient's discharge from the facility.
- Payment Methods: Bank transfer (IBAN provided upon request), credit/debit card, or direct debit. All transactions are processed in Euro (EUR) through licensed Italian financial institutions.
- Scope of Services: The costs outlined in this Quotation Estimate cover the standard surgical pathway. Should the Surgeon determine intraoperatively that additional procedures, extended hospitalization, or specialized interventions are medically necessary, a supplementary Quotation Estimate will be issued and presented to the patient or their authorized representative for written consent before any additional costs are incurred.
- Cancellation Policy: Cancellation by the patient more than fourteen (14) days before the scheduled procedure incurs no charge. Cancellation between seven (7) and fourteen (14) days incurs a fee of 25% of the total. Cancellation within seven (7) days incurs a fee of 50% of the total. The deposit is non-refundable once the operating room has been reserved.
- Regulatory Compliance: All services described in this Quotation Estimate are performed in strict compliance with Italian national health regulations, the Lazio regional health authority guidelines, and the professional code of ethics of the Ordine dei Medici Chirurghi e Odontoiatri di Roma. The Surgeon and all team members carry full professional liability insurance as mandated by Italian law.
- Confidentiality: All patient data, clinical records, and financial information contained in or related to this Quotation Estimate are protected under Italian data protection legislation (D.Lgs. 196/2003) and the EU General Data Protection Regulation (GDPR). No information will be disclosed to third parties without the explicit written consent of the patient.
- Dispute Resolution: Any disputes arising from the interpretation or execution of this Quotation Estimate shall be resolved through amicable negotiation. In the event of unresolved disagreement, the competent civil court of Rome, Italy shall have exclusive jurisdiction.
By signing below, the patient (or their legally authorized representative) acknowledges receipt of this Quotation Estimate, confirms understanding of all itemized costs and terms, and authorizes the Surgeon and the clinical team at Clinica San Pietro di Roma, Italy Rome, to proceed with the described surgical intervention. The patient further confirms that all relevant medical history has been disclosed and that they have had the opportunity to ask questions regarding the procedure, risks, and alternatives.
Patient / Authorized Representative
Name: Dr. Elena Marchetti | Signature: _________________________ | Date: ____________Surgeon / Issuing Physician
Name: Prof. Marco De Santis | Signature: _________________________ | Date: ____________ ⬇️ Download as DOCX Edit online as DOCXCreate your own Word template with our GoGPT AI prompt:
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