Your Health, Your Journey, Your Way
At Travel Well, we help you combine world-class medical treatments with incredible travel experiences. Whether it’s weight loss surgery in Mexico or a family holiday to Fiji, we’ll handle the details, so you can focus on you. Please carefully fill out the form to start processing your quote request.
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First Name
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example@example.com
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Afghanistan
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Travel plans
Number of people traveling:
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2
3
4
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Departure city
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Reason for travel
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Leisure/ Touring Only
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Event
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What are your travel plans? Please give as much detail as possible
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Departure date
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Day
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Day
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Date
Please double check your departure/return date and confirm they are correct.
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Dates are correct
Flexibility in dates
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Dates are flexible
Dates are fixed
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Economy
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Seating preference
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Window
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I am willing to pay extra to secure my preferred seat:
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Would you like to do a stopover?
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Preferred airline(s) if any
Non-Preferred airline(s) if any
Would you like to add any Airline Membership No?
*
Yes
No
Airline Membership No. (only to be provided if available)
Please provide Passenger Name, Airline Name & Airline Membership No. You can provide as many as you like
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Surgery Information
What surgery are you looking into? Select all that apply
*
Bariatric Surgery
Cosmetic Surgery
Bariatric Surgery Options
Gastric Sleeve
Gastric Bypass
Unsure, would like surgeons recommendation
Cosmetic Surgery Options - select all that apply
Breast Augmentation
Breast Lift
Rhinoplasty
Facelift
Reduction Tummy Tuck
Thigh Lift
Liposuction
Dental Work
What destination are you considering?
*
Mexico
Turkey
Thailand
Other
Would you prefer to travel independently or with a travel escort?
*
Independently
Escorted
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Health History
What is your current weight in kg?
*
What is your height in cm?
*
Do you have any pre-existing medical conditions? (e.g., diabetes, hypertension, sleep apnea)
*
Yes - please specify
No
Please specify any pre-existing medical conditions here:
*
Are you currently taking any medications?
*
Yes - please specify
No
Please list any medications you are currently taking here:
*
Have you had any previous surgeries?
*
Yes - please specify
No
Please provide details of any previous surgeries here:
*
Are you wanting to use Kiwisaver and need help completing the application?
*
Yes
No
Is there anything else you would like us to know or any specific questions you have about the surgery?
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Passengers details
Passenger 1
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
Nationality
Date of Issue
-
Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 2
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First Name as per Passport
Last Name as per Passport
Title
*
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Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
Nationality
Date of Issue
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Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 3
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
Nationality
Date of Issue
-
Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 4
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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of
Passport Number
Nationality
Date of Issue
-
Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 5
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
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-
Month
Year
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Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 6
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
Nationality
Date of Issue
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Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 7
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
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-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 8
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
Nationality
Date of Issue
-
Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 9
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
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Passport Number
Nationality
Date of Issue
-
Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
Passenger 10
*
First Name as per Passport
Last Name as per Passport
Title
*
Please Select
Mrs
Mr
Ms
Mx
Miss
Mstr
Dr
Sir
Other
Date of birth
*
-
Day
-
Month
Year
Gender
*
Please Select
Female
Male
Non-binary
Dietary
*
Please Select
No meal requirements
Vegetarian
Vegan
Gluten-Free
Diabetic
Diary-Free
Other
Additional dietary, baggage or mobility information
You can leave this empty if not needed
Passport Details
Please either upload a copy of the picture page of your passport or fill in the below questions - please note you do not need to complete the below passport details if a copy is uploaded.
Browse Files
Drag and drop files here
Choose a file
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of
Passport Number
Nationality
Date of Issue
-
Day
-
Month
Year
Date
Date of Expiry
-
Day
-
Month
Year
Date
Please only tick this box if you are renewing your passport:
I am needing to renew my passport and will advise details once this is done
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Would you like to add any hotel or rental car membership No.
*
Yes
No
Additional information
Other Memberships (only to be provided if available)
Please provide Passenger Name, Provider & Hotel / Rental car Membership No.
We strongly recommend Travel Insurance for all domestic and international travel. Shall we include a quote for you?
*
Yes
No
Do you need insurance for a pre-existing medical condition?
*
Yes
No
Would you like to receive xtravel’s E-Newsletter?
*
Yes
No
Acknowledgement
*
I acknowledge that I have spelt the names correctly as per the passports and any difference to this on the actual passports will result in airline fees to change tickets and flight reservations.
Signature
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About us
We’re obsessive travellers with a wealth of experience providing travel services to all those who travel for work or play. We strive to offer exceptional experiences to enhance our clients’ travels and offer full 24 hour support while you are on the road. Whether you’d like an escorted tour in Ecuador, a snow experience, a cruise in the Caribbean, full service corporate and business travel, or a family holiday abroad, we have the knowledge and expertise to ensure you get more out of your travel.
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