Taqtik Health - Medical Visit™

Request Medical Visit and Your Information

Completely confidential with no obligation!
We invite you to complete the form below to receive a detailed FirmQuote™ for your particular procedure(s). Simply select your preferred destination, hospital, or surgeon (if known), and we will obtain your personal feedback with a confirmed firm price. Surgeon feedback can take up to 5 business days.

If you requesting another quote and have already submitted your information please indicate below.
Client Status

This is my first inquiryNew Quote Request. Please use existing file information
Name

First NameLast Name
Patient Gender
Patient Birth Date

MonthDayYear
Age
Nationality
Height
Weight
Contact Information

Please complete the information below
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Mobile Number

Area CodePhone Number
E-Mail

Health Check or Treatment Request

Please tell us the procedures you are interested in
Preferred Destination
Preferred Hospital or Clinic (If Known)
Do you have a preferred surgeon?
Requested Procedure(s)
Requested Procedure(s)
Requested Procedure(s)
If not mentioned above please add treatments
What are Your Personal Goals for having Surgery
Anything you want to ask or tell the surgeon?
Requested Date of surgery (If Known)

MonthDayYear
Date
Arrival Date (If Known)

MonthDayYear
Date
Departure Date (if known)

MonthDayYear
Date

Hotel and Accommodation
We have excellent accommodation options in both hotels or serviced apartments. Our preferred accommodation options are specially selected to suit the medical traveler. They are close to the hospitals/clinics, are well priced, and close to amenities. All accommodation is priced for 2 people, including breakfast for 2. Additional options for families and large groups.
Do you Need Accommodation?

Yes, Please quoteNo, already bookedUndecided, will get back
Accommodation Hotel
Number of Nights
Please advise your itinerary if staying in a non-Gorgeous Getaways preferred hote
Thank You for Completing!

PLEASE SUBMIT BELOW WHEN COMPLETE.
We will forward this information to your surgeon for review and feedback. In the interim please let us know if you have any questions.
More More Information please visit www.gorgeousgetaways.com
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Request Medical Visit and Your Information