Booking form





Please print out this form and fill in your details. Please fax your completed booking form to: +44  1814058021.  


1-Reason for visiting London Medical treatment  or accompanying/visiting someone who is)

2- Tel: 
   Fax: 

3-Personal: Details of Illness, and how did you know of Doctorinternet service(Friend, newspaper,television,mgazine...etc)

4- Full name : exactly as in Pasport
5- Full Address ( Including Tel Number, fx and e-mail)

6- Does the patient need immedciate attention and How, please specify

7-Type of treatment needed in London

8-Did the speciailist of Doctorintenret and your doctor back home recommend help during travel? Yes /No? please give details of the specialsit(s) Name,Tel, Fax and e-mail

8-Accommodation: Would you like Doctorinternet to book for you a suitable accomodation? Yes/No?
Do you require apartment accommodation? Yes/No
Do you require hotel accommodation? Yes/No
What standard of accommodation do you require? 2* / 3* / 4* / 5*

What are your room and bed requirements?
Number of rooms
Single (one single bed)
Double (one double bed)
Twin (two single beds)
Triple (three single beds)
Triple (one double, one single bed)
Do you require any cots? Yes/No If so, how many?
Do you have any other requirements?


9- Arriving and departing

All passengers arriving at London's Heathrow and Gatwick Airports will be met by one of our representatives, so please give us details of your flight

Arrival date: 
Airport: 
Flight Number: 
Arriving from: 
Arrival time: 
The person who meets you at the airport will speak English. If you need them to speak another language, please specify: 
Will you need transport to your accommodation? Yes/No
Will you need transport to the airport on your departure? Yes/No
If so, please give details of your flight:
Departure date:
Airport:
Flight Number:
Destination:
Departure time:
Do you have any particular transport requirements, such as a limousine, or a vehicle that will take a wheel  chair?


If you would like us to book your flights, please give us details of your journey.  

Date of travel to London:
Departure airport: 
Preferred airline:
Preferred outward flight time:
Date of return travel:
Preferred return flight time:
Bottom of Form 6
Other Services

Please let us know of anything else you would like our help with. The services we can offer include interpreters, sightseeing, theatre tickets, flower delivery and hotels outside London, including health spas.

Payment 

We will contact you within 24 hours of receiving this form. You will receive a booking reference number, which you will need to quote in all correspondence.
Payment can only be made by credit card. Apartment bookings must be paid for in full upon confirmation. For other reservations, provided there is more than eight weeks to go before your arrival, you will pay a 10% deposit. The balance of your payment must then be made in full at least eight weeks before your arval.
I have read and understand the general booking conditions and agree to abide by them.
Signed:
Date:



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