Quotation Estimate Surgeon in Netherlands Amsterdam –Free Word Template Download with AI
Professional Surgical Services — Netherlands Amsterdam
1. CLIENT INFORMATION| Field | Details |
|---|---|
| Patient / Client Name | Mr. Jeroen de Vries |
| Address | Herengracht 245, 1017 BX Amsterdam, Netherlands |
| Insurance Provider | Zorgverzekeringsmaatschappij Amsterdam (ZVA) — Policy No. ZVA-88231 |
| Contact Telephone | +31 20 555 0142 |
| [email protected] |
This Quotation Estimate is issued by Dr. Hendrik van der Berg, a board-certified Surgeon practising at the Amsterdam University Medical Centers (UMC Amsterdam), located in the heart of Netherlands Amsterdam. The following surgical procedures and associated services have been recommended following a comprehensive diagnostic consultation conducted on 28 May 2025. All services are performed in accordance with the Dutch Medical Treatment Act (Wet medisch treatment) and the professional standards set by the Royal Dutch Medical Association (KNMG).
3. ITEMIZED COST BREAKDOWN| Ref. | Description of Service | Quantity | Unit Price (EUR) | Total (EUR) |
|---|---|---|---|---|
| 01 | Pre-operative surgical consultation and physical examination by the Surgeon | 1 session | € 285.00 | € 285.00 |
| 02 | Diagnostic imaging (CT scan and abdominal ultrasound) at UMC Amsterdam radiology department | 1 package | € 620.00 | € 620.00 |
| 03 | Pre-operative laboratory blood work and anaesthesia assessment | 1 package | € 340.00 | € 340.00 |
| 04 | Laparoscopic cholecystectomy (minimally invasive gallbladder removal) performed by the Surgeon | 1 procedure | € 4,850.00 | € 4,850.00 |
| 05 | General anaesthesia services (anaesthesiologist and anaesthetic agents) | 1 session | € 1,200.00 | € 1,200.00 |
| 06 | Operating theatre usage fees (surgical suite, instruments, sterile supplies) at UMC Amsterdam | 1 session | € 1,450.00 | € 1,450.00 |
| 07 | Post-operative hospitalisation (24-hour recovery ward, nursing care, monitoring) | 1 night | € 1,100.00 | € 1,100.00 |
| 08 | Post-operative follow-up consultation with the Surgeon (day 7 and day 21) | 2 sessions | € 195.00 | € 390.00 |
| 09 | Prescribed post-operative medication and wound care supplies | 1 package | € 185.00 | € 185.00 |
| 10 | Pathological examination of excised tissue (histology report) | 1 sample | € 420.00 | € 420.00 |
| SUBTOTAL | € 10,840.00 | |||
| Dutch VAT (21%) | € 2,276.40 | |||
| GRAND TOTAL | € 13,116.40 | |||
- This Quotation Estimate is valid for a period of thirty (30) calendar days from the date of issue. After this period, pricing may be subject to revision based on current hospital fee schedules in Netherlands Amsterdam.
- The Surgeon reserves the right to modify the surgical approach (e.g., converting from laparoscopic to open surgery) if intra-operative findings warrant it. Any such modification will be communicated to the patient's designated contact person immediately.
- Payment is due within fourteen (14) calendar days of the date of the final invoice, which will be issued following the completion of all post-operative follow-up sessions. Payment may be made via bank transfer to the UMC Amsterdam accounts department (IBAN: NL91 ABNA 0417 1643 00) or through direct insurance settlement where applicable.
- The patient acknowledges that all surgical procedures carry inherent risks. A detailed informed consent form, prepared in Dutch and English, will be signed by the patient prior to the procedure. The Surgeon will ensure that all risks, benefits, and alternative treatments are explained in accordance with Dutch medical-legal standards.
- This Quotation Estimate does not constitute a guarantee of a specific medical outcome. The Surgeon will exercise the highest standard of care consistent with the prevailing medical practice in the Netherlands.
- All personal health data processed in connection with this Quotation Estimate and the subsequent surgical treatment will be handled in strict compliance with the Dutch Implementation Act GDPR (UAVG) and the European General Data Protection Regulation.
- Any disputes arising from this Quotation Estimate or the services described herein shall be subject to the jurisdiction of the competent court in Amsterdam, Netherlands.
By signing below, the patient confirms that this Quotation Estimate has been reviewed, all questions have been addressed by the Surgeon, and the patient consents to proceed with the outlined surgical plan at UMC Amsterdam, Netherlands Amsterdam.
Patient / ClientName: Jeroen de Vries
Date: _______________ Surgeon / Issuing Physician
Name: Dr. Hendrik van der Berg, MD, FACS
Date: _______________ ⬇️ Download as DOCX Edit online as DOCX
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