Medical Quotation for Hospital Example – [Edit & Download]
Header
- Quotation Title: Hospital Medical Quotation
- Date: February 21, 2025
- Quotation Number: HQ20250221-4567
Provider Information
- Hospital Name: Central Hospital
- Address: 456 Medical Plaza, Meditown, State, 67890
- Contact Information: (456) 789-0123, contact@centralhospital.com
Patient Information
- Name: Jane Smith
- Patient ID: 123456789
- Contact Details: (789) 012-3456, janesmith@email.com
Medical Services Description
| Service | Description | Quantity | Unit Price | Total Price |
|---|---|---|---|---|
| Emergency Room Visit | Initial assessment and treatment | 1 | $800 | $800 |
| X-Ray | X-Ray of the left ankle | 2 | $150 | $300 |
| Overnight Stay | One night stay in a standard hospital room | 1 | $500 | $500 |
| Surgical Consultation | Consultation with a surgeon for potential surgery | 1 | $350 | $350 |
| Blood Tests | Complete blood count (CBC) and metabolic panel | 1 set | $100 | $100 |
| MRI Scan | MRI of the brain | 1 | $1200 | $1200 |
| Follow-up Consultation | Follow-up visit with a specialist | 1 | $250 | $250 |
Summary
- Subtotal: $3500
- Taxes: $315 (9% sales tax)
- Grand Total: $3815
Terms and Conditions
- Payment Terms: Full payment required within 15 days of the invoice date
- Validity: This quotation is valid for 30 days from the date of issuance
- Additional Information: Cancellations of scheduled services must be notified at least 48 hours prior to the appointment to avoid a fee.
Signature
- Authorized Signature: [Signature of Hospital Administrator]
- Date: February 21, 2025
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