DR ETIENNE SWANEPOEL Ingelyf / Incorporated Reg No: 99/21832/21 MBCh B (UOVS) FCS (SA) MMed (Stell) ALGEMENE CHIRURG / GENERAL SURGEON
PR 4207912 DURBANVILLE PRIVAAT/PRIVATE HOSPITAAL/HOSPITAL KAMER /SUITE G08 WELLINGTONWEG /ROAD 45 PRIVAATSAK /PRIVATE BAG X15 DURBANVILLE 7550
TEL : 021- 975-2594 /5 FAX : 021- 975–2692 e-mial: etienne@capesurgeon.com
Date: …………..……
Our ref: ………..…. QUOTATION
PATIENT: ……………………………….. DR E SWANEPOEL: (contracted out) Code 1807 – Laparoscopy Code 1617 – Partial gastrectomy Code 1641 – Entero-enterostomy Code 1613 - Gastroenterostomy Code 0008 – Assistant TOTAL: Theatre time: ± 3 hours Diagnosis/ ICD-10: E66.9
Our tariff
R 32 500.00 BMI: ……. kg/m²…
IMPORTANT: 1. The FULL quote is payable BEFORE a theatre date is booked. Limited theatre dates available. 2. NO tentative bookings made. 3. 10% Cancellation fee will be charged if cancelled within 2 weeks before procedure. ANAESTHETIST Dr L Evenepoel 021 424-7208 OR Dr N Botha 021 939 7080 OR Dr N Coetzee 021 914 1105 N1-CITY HOSPITAL Please ph: 021 590-4444 for a quotation. Theatre time: ± 3 hours. Days in hospital: ± 3-5 days. BMI > 60 = ±R87 000; BMI< 59 = ±R72 000. Estimated cost for 2011. No fees received for 2012 yet. DURBANVILLE MEDI-CLINIC Please ph: 021 980 2100 for a quotation. Theatre time: ± 3 hours. Days in hospital: ± 3-5 days. BMI > 60 = ±R87 000; BMI< 59 = ±R72 000 for 2011. BMI > 60 = ±R95 700; BMI< 59 = ±R87 000 for 2012. This is just estimation. DR E SWANEPOEL
I, …………………………………………., ID no: ……………………………., accept the quotation.
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**NOTE: PLEASE SIGN AND SEND BACK BEFORE THE DAY OF PROCEDURE.** *AN UNSIGNED QUOTE WILL CAUSE THE PROCEDURE TO BE POSTPONED OR CANCELLED* BANK ABSA PAROW BRANCH CODE 502110 DR E SWANEPOEL CHEQUE ACC NO: 390 176 090