Booking Form

First Name:

Last Name:

E-mail:

Date of birth (MM.DD.YYYY):

Nationality::

Passport Number:

I wish to book the following procedures:

I am only interested in the surgery and hospital stay
I want to book accommodation in Bangkok.
I want to book the transfer package in Bangkok.
I want to book accommodation in Hua Hin
I want to book the transfer package in Hua Hin Package

If you wish to make your own travel arrangements, please inform us where you will be staying in case we need to contact you during your stay in Thailand:

Optional

I would like to upgrade my hotel to 5-star option
I would like to add the Bangkok Transfer Package

Time of holiday

Please inform us of your desired time of appointment. If you do not know the exact date yet, please provide an approximate date.

Appointment (MM.DD.YYYY):

Arrival Date (MM.DD.YYYY):

Arrival Time:

Flight Number:

Departure Date (MM.DD.YYYY):

Departure Time:

Flight Number:

Accompany

Yes

No

Do you wish to bring a companion along?

Will your companion stay with you during your admission?

Disclaimer
Hygeia Healthcare helps you find medical treatment opportunities abroad. The role of Hygeia Healthcare is to act as a marketing agent for medical facilities and arrange medical treatment packages with the option to include a holiday package. The agreement to have surgery is strictly between the patient and the hospital. The final decision about whether the patient is a candidate for the chosen procedure(s) will be made by the surgeon during the pre-surgery evaluation. Hygeia Healthcare does not offer any medical advice and is in no way liable for the actions of third parties. You are aware of and acknowledge the role of Hygeia Healthcare as described. You further accept that the decision to have medical treatment abroad is your decision and that you are aware of any risks involved.

I have read and understand the disclaimer and agree to the terms specified.