The experts in Medical Tourism: For your peace of mind

PO Box 219, Alexandria, NEW SOUTH WALES, 1435, SYDNEY AUSTRALIA

Email: marnie@medimakeovers.com
0414 258 875

All Administration forms must be accompanied with the AUD $200.00 non-
refundable Dental administration fee. This can be paid by direct transfer, money
order or bank cheque. Payment for all surgery expenses is payable direct to the
hospital after your consultation with your surgeon. Payment for all accommodation
is paid direct to your chosen accommodation.

The fields marked with * are required

PERSONAL
DATA
*Full Name: *Date of
As appears on birth:
passport dd/mm/yyyy
*Phone: *Mobile:
*Passport
Number: *Gender:
*Country of
residence: *Nationality:
*Email
address:
*Current
Address:
EMERGENCY
CONTACT
*Phone
*Name :
Relationship to
*Email: you
*Address:
SURGERY / DENTAL PROCEDURES
*Booked
Procedure(s)
FLIGHTS
*Arrival date and *Flight
time *Airline No.
*Departure date *Flight
and time *Airline No.
*Are you travelling alone? If not please name all persons travelling with you.
Please state ages of children
 *ACCOMMODATION CONFIRMATION

Please choose:

Luxury Suites

Centre Point
Apartments

Grand Millennium
Your own booking,
Please name hotel,
address & phone
* METHOD OF PAYMENT
Cash ( Direct Transfer (
Cheque (

Bank details for deposit/transfer: Mail cheque or money order to:

Bank: Westpac DM Concepts Pty Ltd
BSB: 032 051 PO Box 219
Account No: 118099 Alexandria NSW 1435 Australia
Account Name: DM Concepts Pty Ltd
(Trading as Medi Makeovers)

(Please use your surname as the reference when direct deposit)

Have you read and agreed to our disclaimer? ( Yes ( No
Have you read and agreed to our cancellation policy? ( Yes (
No
Please view on website – www.medimakeovers.com
Patient Declaration:

I, (Patient’s name): ________________________________, declare that I have

truthfully completed the entirety of this form and that I have not made
any purposeful omissions.

Signed: _______________________________ Date: _______________________

Return Form:
1. Save document and complete.
2. Print, sign and date document.
3. Scan and email back OR mail to PO Box 219, Alexandria, NSW, 1435,
Australia.

Thank you