PATIENT TRAVEL INFORMATION

Please answer the following question to assists with the creation of your itinerary.

We look forward to elevating your quality of life at Renue Medical Centre:

Name

First Name

Last Name

Phone number

Country

(###)

###

####

Once your flights are booked, please provide the following information as it is shown in your ticket

Arrival Date:

YYYY

Arrival Time:

Flight Details:

Please provide airline and flight number

Departure Date:

YYYY

Departure Time:

Flight Details:

Please provide airline and flight number

Hotel/condo name:

If possible, please provide the address

Special requests to consider prior and during your stay:

Patient Advisor's Name: