Quotation Estimate Surgeon in United States San Francisco –Free Word Template Download with AI
Professional Surgeon Services — United States San Francisco
| Quotation Estimate No.: | SF-SRG-2025-04871 |
| Date of Issue: | June 12, 2025 |
| Valid Until: | July 12, 2025 (30 calendar days) |
| Prepared By: | Dr. Margaret L. Chen, MD, FACS — Lead Surgeon, Pacific Surgical Associates |
| Service Location: | United States San Francisco, California — 1200 Market Street, Suite 4500, San Francisco, CA 94102 |
| Client / Requesting Party: | Bay Area Medical Group, LLC — Attn: Director of Procurement |
| Contact Email: | [email protected] |
This Quotation Estimate is issued by Pacific Surgical Associates to formally outline the projected costs, professional fees, and associated expenses for the engagement of a board-certified Surgeon to provide specialized surgical services within the United States San Francisco metropolitan area. This document serves as a comprehensive financial projection and is intended to assist the requesting party in budgeting, insurance coordination, and administrative planning. All figures presented herein are estimates based on current market rates as of the date of issue and are subject to the terms and conditions outlined in Section 6 of this document.
The Surgeon referenced in this Quotation Estimate holds the following credentials and qualifications, all verified and current as of the date of this document:
Board Certified in General Surgery and Vascular Surgery by the American Board of Surgery. Fellowship trained in Minimally Invasive and Robotic Surgery at Stanford University School of Medicine. Licensed to practice medicine in the State of California, License No. CA-1048723. Member of the American College of Surgeons (FACS). Over 18 years of clinical experience performing complex surgical procedures in the United States San Francisco region, including at UCSF Medical Center and San Francisco General Hospital. Annual malpractice insurance coverage maintained at a minimum of $5,000,000 per occurrence.
| Item No. | Description of Service | Unit | Qty | Unit Cost (USD) | Subtotal (USD) |
|---|---|---|---|---|---|
| 01 | Pre-operative Surgical Consultation and Patient Assessment (Surgeon time, diagnostic review, surgical planning) | Session | 2 | $1,250.00 | $2,500.00 |
| 02 | Primary Surgical Procedure — General/Minimally Invasive Surgery (Surgeon operative time, first 60 minutes) | Hour | 3 | $4,800.00 | $14,400.00 |
| 03 | Additional Surgeon Operative Time (beyond initial 3 hours, billed in 15-minute increments) | 15 min | 4 | $600.00 | $2,400.00 |
| 04 | First Assistant Surgeon Fee (if applicable, per operative session) | Session | 1 | $3,200.00 | $3,200.00 |
| 05 | Post-operative Recovery Room Monitoring and Surgeon Supervision (first 4 hours) | Block | 1 | $1,800.00 | $1,800.00 |
| 06 | Post-operative Follow-up Visits (Surgeon examination, wound assessment, suture removal) — United States San Francisco clinic | Visit | 3 | $450.00 | $1,350.00 |
| 07 | Emergency Post-operative Consultation (24/7 availability, United States San Francisco coverage zone) | Call | 1 | $950.00 | $950.00 |
| 08 | Surgical Pathology and Laboratory Coordination Fees (Surgeon-directed) | Flat | 1 | $2,100.00 | $2,100.00 |
| 09 | Medical Record Documentation and Billing Administration (Surgeon's office, San Francisco) | Flat | 1 | $350.00 | $350.00 |
| 10 | Travel and Logistics Surcharge (if procedure requires travel outside central San Francisco, United States) | Flat | 1 | $275.00 | $275.00 |
| ESTIMATED TOTAL (USD): | $31,325.00 | ||||
All fees listed in this Quotation Estimate are subject to applicable California state and local taxes as mandated by the State of California and the City and County of San Francisco. The current combined sales and use tax rate for medical services in the United States San Francisco jurisdiction is 8.63%. Additionally, any applicable Medicare or private insurance co-payments, deductibles, or out-of-pocket maximums will be the responsibility of the patient or the requesting medical group and are not included in the subtotal above. The Surgeon's office will provide a detailed itemized invoice upon completion of services for insurance submission purposes.
Payment for services rendered under this Quotation Estimate shall be structured as follows: a non-refundable deposit of 25% of the estimated total is due upon acceptance of this document and scheduling confirmation. The remaining 75% is due within thirty (30) calendar days of the final post-operative visit. All payments are to be made via certified check, wire transfer, or approved electronic payment method to Pacific Surgical Associates, P.O. Box 4471, San Francisco, CA 94124. Late payments shall accrue interest at a rate of 1.5% per month or the maximum rate permitted by California law, whichever is lower. Insurance claims will be filed on behalf of the patient within ten (10) business days of service completion.
6.1 This Quotation Estimate is a good-faith projection and does not constitute a binding contract until formally accepted in writing by both parties. Actual costs may vary based on intra-operative findings, extended procedure duration, or unforeseen complications requiring additional Surgeon intervention.
6.2 The Surgeon reserves the right to modify the surgical plan intra-operatively if patient safety necessitates a deviation from the originally planned procedure. Any such modifications will be communicated to the patient's designated representative prior to implementation, and associated costs will be itemized separately on the final invoice.
6.3 All services will be performed in compliance with the California Business and Professions Code, the American College of Surgeons accreditation standards, and all applicable federal regulations governing surgical practice in the United States San Francisco area.
6.4 This Quotation Estimate is valid for thirty (30) days from the date of issue. After the expiration date, all fees are subject to revision based on current market conditions, supply costs, and the Surgeon's updated fee schedule.
6.5 Neither party shall be liable for indirect, incidental, or consequential damages arising from the engagement described herein. The Surgeon's liability is limited to the total amount paid under this estimate.
6.6 This document is governed by the laws of the State of California. Any disputes arising from this Quotation Estimate shall be resolved through binding arbitration in San Francisco, United States, in accordance with the rules of the American Arbitration Association.
By signing below, the requesting party acknowledges receipt of this Quotation Estimate, confirms understanding of the projected costs for the Surgeon's services in United States San Francisco, and agrees to the terms and conditions set forth in this document. This acceptance authorizes the scheduling of the surgical engagement and the initiation of pre-operative preparations.
Authorized Representative — Bay Area Medical Group, LLC
Date: ____________________
Dr. Margaret L. Chen, MD, FACS
Pacific Surgical Associates — San Francisco, CA
Date: ____________________
Create your own Word template with our GoGPT AI prompt:
GoGPT