Beverly Wilshire - Prebooking Form

PRE-BOOKING FORM
Pre-booking for this promotion is subject to availability, the current Covid-19 situation and travel restrictions in place. This offer is limited to all tentative booking dates received up till April 30th only and will not be extended. It also assumes you have completed a firmquote request in the past 12 months. If you have not done this, please complete a firmquote request instead. If you have any questions please do not hesitate to contact us.
Patient Information
Patient Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient E-Mail
Home Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
Hospital and Procedures
Destination
Hospital or Clinic
Requested Procedure(s)
Requested Procedure(s)
Requested Procedure(s)
Additionanal Comments
Pre-Booking Dates

Please leave arrival and departure dates emply if flights not booked
Requested Date of surgery

MonthDayYear
Date
Planned Arrival Date

MonthDayYear
Date
Planned Departure Date

MonthDayYear
Date
Confirmation
CONFIRMATION AND RECEIPT

Your surgery date is based on availability at the time of booking. Once you submit below, you will be provided with a confirmation. We will confirm availability on these dates requested wit you once we receive confirmation. If you have any questions at any time please contact your consultant, and thank you for considering Gorgeous Getaways.
Please sign here to confirm.

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More More Information please visit www.gorgeousgetaways.com
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PRE-BOOKING FORM

Patient Information

Hospital and Procedures

Pre-Booking Dates

Confirmation