Gorgeous Getaways - Australia FirmQuote™

Request Your Firmquote

Completely confidential with no obligation!
Client Status*

This is my first inquiryNew Quote Request. Please use existing file information
Name*

First NameLast Name
Patient Gender*
Patient Birth Date*

MonthDayYear
Medicare Number*
Interested in using Superannuation?

Yes, I want to see if I qualifyNo, I do not want to use superannuationUndecided
Height*
Weight*
Contact Information

Please complete the information below
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
E-Mail*

Surgery Details

Please tell us the procedures you are interested in
Preferred Destination*
If destination not listed, please indicate
Treatment Category*
Please list requested procedures*
What are your personal goals and expectations for having surgery
Anything you want to ask or tell the surgeon?
When are you interested in having your consultation (tentative dates). Dates will be confirmed with the hospital/clinic/surgeon.
When are you interested in having surgery (tentative dates)-Dates will be confirmed with the hospital/clinic/surgeon.

Hotel and Accommodations
If traveling interstate will you need ground services and/or accommodation?
Do you Need Accommodation?*

Yes, Please quoteNo, not requiredUndecided, will get back
Type of accommodation or services required.
Number of Nights
Australia has some of the most stringent patient privacy and confidentiality laws in the developed world. Gorgeous Getaways and its partners adhere to the strictest standards of patient privacy and confidentiality. For more information on our policy, technology or process please contact us at care@gorgeusgetaways.com
Thank You for Completing!

PLEASE SUBMIT BELOW WHEN COMPLETE.
We will forward your medical history and photos to our Surgeons for review and feedback. We will send your firmquote in 3-5 days. In the meantime, let us know if you have additional questions.
More More Information please visit www.gorgeousgetaways.com
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Request Your Firmquote