Booking Form

Please complete the following form for your holiday and treatments. Please give as much information as possible in all cases, especially your health and medical history.

All people having surgery is required to fill in the following forms. If you are travelling with another who is having surgery, please ensure that you forward this form to them to fill in.

All bookings must be accompanied by payment for accommodation, which can be paid by credit card or direct transfer. Payment for all surgery and dentistry treatments is payable direct to the hospital after the consultation with the surgeon, when you are happy and agree to go ahead.

IMPORTANT! Please read carefully:
Payment for your surgery has to be made in Cash or Credit Card. If you plan to bring cash (in the form of traveler's cheques), please inform your customer service manager to assist you - you will be taken to the nearest bank to cash them. If you are doing bank transfers, the money has to be cleared 7 days before your surgery day. If your payment is not available on surgery day, your surgery will be cancelled or postponed. Please note we do not accept personal cheques.

ALL FIELDS ARE COMPULSORY FOR BOOKINGS:	I would like to book my surgery holiday*:
First Name*: (as per passport)
Last Name*: (as per passport)
*Email address:**	(please note: with Hotmail, Yahoo or AOL accounts, our response to you may be directed to your Bulk folder. Please can you Whitelist "info@gorgeousgetaways.com" in your account, and also specify an alternative account for these addresses)
2nd email address if you have one:
Phone:
Mobile Phone:
Street Address:
City:
*State/Province:**
Zip/Postcode:
*Country:**
Date of birth: (dd/mm/year)
Age:

Next of Kin:
Next of Kin Name:
Next of Kin contact (email address or phone):
Next of Kin relationship to you:
Would you like us to update this person after your surgery?	Yes, please contact
Passport number (for hospital):
Where did you hear about Gorgeous Getaways?:	If a friend referred you to us, please write their name here so we can give your friend a gift.

Your Surgery:
Who is the Surgeon/Hospital you would like to book with?
Your Surgery Treatments:
If not on the list above, please list the treatments that you would like:
Important Note: Due to the complexity that dental can be, we cannot give you a guarantee of the amount of days that you need to travel – this will only be given to you after a thorough consultation with the surgeon. We suggest that you remain flexible with your travel plans in case you need to stay longer away eg. purchase a flexible air ticket. Gorgeous Getaways cannot be responsible for extension costs on your flights and accommodation if the dentist requires you to stay longer to complete your treatment plan.
What are your personal goals of having surgery?

Your Holiday:
Accommodation /Hotel:
Your Itinerary - if staying in different hotels, please give details and dates:
Number of Adults:
Number of Children:
Name of other people travelling:
Arrival date (DD/MM/YEAR):
Departure date (DD/MM/YEAR):
How many nights:
Flight arrival time:
Flight arrival airline and number:
Flight departure time:
Flight departure airline and number:

*Other Questions*
What are the most important factors for you on your surgery holiday? (you can choose more than 1 by holding down the CTRL key)
Do you have any other questions or requests?