BOOKING AND CREDIT CARD PAYMENT FORM |
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Please complete this form and to confirm your booking, authorize the deposit payment requested (For the package rate or the quoted invoice amount) and fax to + 90 232 279 29 55
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| Information | |||||||||||
| Name of the treatment | |||||||||||
| *Name and Surname of the patient | |||||||||||
| *Street address | |||||||||||
| *Country | |||||||||||
| City-State-Zip | |||||||||||
| *Home telephone | |||||||||||
| *Date of birth | |||||||||||
| Citizenship | |||||||||||
| *Passport number | |||||||||||
Please print the services you are booking and making payment for : |
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Beginning and ending dates of your surgical operation with Revitalizeinturkey in Turkey : |
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Beginning date |
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Ending Date |
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| Vacation travel insurance: We strongly recommend that you purchase a vacation travel protection plan offered in your home country which includes trip cancellation insurance, medical, baggage and accident insurance. |
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| CARD NUMBER | |||||||||||
| EXPIRY DATE | |||||||||||
| CARD cvv2/cvc2 NUMBER | |||||||||||
| Print name exactly as it appears on card | |||||||||||
| Currency | |||||||||||
| Payment amount In writing | |||||||||||
I agree the above mentioned amount to be charged to my creditcard account for above mentioned services or tour package,I ordered from you |
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| Signature : | _____________________ | Date : | ____________________ | ||||||||
I have read and agree to the terms & conditions of the services booked as above |
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