The PREMIER Experience

1
First, Let's get your Contact Information.* This field is required.What is your name?
First Name
Last Name
2
Hello, nice to meet you! Now, we need your email.* This field is required.Please provide a working email that we can send you important documents for your stay.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
3
Thanks so much..What is your phone number?* This field is required.We may call but will mostly text to communicate with you.
Please enter a valid phone number.
4
What is your Address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Have you booked your surgery?Please let us know when.
If you do not have this right now, please let us know ASAP.
Month
Day
Year
6
Who is your Surgeon?* This field is required.
7
What type of Surgical Procedure?* This field is required.Please list below what kind of surgery you are having.
8
Let's get you booked with us!* This field is required.Would you like a PRIVATE or SHARED Suite?
Please Select
Please Select
Private Suite (1 per Room)
Shared Suite (2 per Room)
9
Do you have any Allergies?* This field is required.
YESNO
10
What kind of Allergies?* This field is required.Please list below.
11
Do you need Lymphatic Drainage Treatments?* This field is required.
YESNO
12
Great! When would you like to stay with us?* This field is required.Check-In is available anytime after 11:30am.
13
Do you need Transportation from the Airport?
Yes Please! - Pick me up on arrival
No Thanks - I'll make my own way there
14
Flight InformationPlease include the date you arrive, flight number and which airline
Please include what airline you are flying with.
15
Are You Ready to Book?Please reserve your stay with your deposit of $250.00.
Ready to Book/Reserve My Spot!
Pay My Deposit Later
16
FINALIZE YOUR RESERVATION BY REMITTING YOUR BOOKING DEPOSITYour deposit is required to hold your spot.
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ORDER SUMMARY
Total costUSD
BOOKING DEPOSITA Non-Refundable Deposit is required to book with us. Your deposit will be applied towards your total stay!
$250.00Edit
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1
1
Quantity
Total cost $0.00
Payment Methods
Credit Card
First Name
Last Name
Cash App
After submitting the form, you will be redirected to the Cash App Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
17
Waiver of LiabilityPlease read thoroughly and click "Next" to Sign
18
Signature of Waiver of Liability * This field is required.By signing below, I agree to hold Premier Recovery Suites/Aftercare free from any liability, including financial responsibility for injuries incurred. I also agree to all rules and regulations stated above.
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