Traveller profile
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Preferred name
*
First Name
*
Last Name
Mobile Number
*
-
Country
Phone Number
Primary email address
*
example@example.com
Address
*
Street Address
Street Address Line 2
Suburb
City
Postal / Zip Code
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
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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
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eSwatini
Sweden
Switzerland
Syria
Taiwan
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Tanzania
Thailand
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Tokelau
Tonga
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Turkey
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Vanuatu
Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
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Travel plans
Number of people traveling:
*
Please Select
1
2
3
4
5
6
7
8
9
10
Departure city
*
Reason for travel
*
Please Select
Leisure/ Touring Only
Medical Only
Leisure/ Touring & Medical
Special occasion
*
Please Select
No special occasion
Event
Birthday
Anniversary
What are your travel plans? Please give as much detail as possible
*
Departure date
*
-
Day
-
Month
Year
Date
Return date
*
-
Day
-
Month
Year
Date
Please double check your departure/return date and confirm they are correct.
*
Dates are correct
Flexibility in dates
*
Please Select
Dates are flexible
Dates are fixed
Travel class
*
Please Select
Economy
Premium Economy
Business
First Class
Other
Seating preference
*
Please Select
Window
Aisle
Forward
Rear
Exit-row
Extra legroom
Other
I am willing to pay extra to secure my preferred seat:
Yes
No
Would you like to do a stopover?
*
Please Select
Yes stopover
No stopover
Please provide stopover information
*
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.
Browse Files
Drag and drop files here
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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 2
*
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
Cancel
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 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.
Browse Files
Drag and drop files here
Choose a file
Cancel
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 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.
Browse Files
Drag and drop files here
Choose a file
Cancel
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.
Browse Files
Drag and drop files here
Choose a file
Cancel
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 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.
Browse Files
Drag and drop files here
Choose a file
Cancel
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 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.
Browse Files
Drag and drop files here
Choose a file
Cancel
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 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.
Browse Files
Drag and drop files here
Choose a file
Cancel
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 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.
Browse Files
Drag and drop files here
Choose a file
Cancel
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 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
Cancel
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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Additional information
Would you like to add any hotel or rental car membership No.
*
Yes
No
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
*
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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