Patient Application

Please enable JavaScript in your browser to complete this form.
Step 1 of 2

Patient Address


Emergency Contact

Home Physician or Healthcare Provider Details

Has Your Procedure Been Cleared By Your Physician and/or Healthcare Provider?
Medical clearance by your physician or healthcare provider must be obtained. If you already have a clearance, please click "YES" and upload it below with any medical documents, recent lab test, x-ray, MRI...etc.

Treatment / Surgery Required

Final decision for the surgery/procedure date to be decided by the physician/surgeon.

Medical Trip Companion

Will Anyone Accompany You?
Companion Sex
Click or drag files to this area to upload. You can upload up to 4 files.
Please upload a clear copy of your and your companion passports. Allowed Formats: .PDF, .JPG, .TIFF, .PNG, .SVG