BOOKING AND CREDIT CARD PAYMENT FORM |
|||||||||||
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
|
|||||||||||
| 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 : |
|||||||||||
|
|
|||||||||||
Beginning and ending dates of your surgical operation with Revitalizeinturkey in Turkey : |
|||||||||||
Beginning date |
|
|
|
Ending Date |
|
|
|||||
| 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. |
|||||||||||
|
|||||||||||
| 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 |
|||||||||||
| Signature : | _____________________ | Date : | ____________________ | ||||||||
I have read and agree to the terms & conditions written below, of the services booked as above |
|||||||||||
Discrepancy In case of medical discrepancy or conflict for imputability of malpractice carried out by the patient, the parts establish and agree that all judicial action must be carried out by the patient towards the surgeon / professional within the jurisdiction of the İzmir of the Republic of Turkey, and that action will not be extended towards Tunçelli Ltd, since it is a company that puts at the disposition of the patient different professional option without exercising medicine professionally Privacy Policy The privacy and the confidentaility of all the information submited by prospective clients to revitalizeinturkey is an issue having an utmost significance for revitalizeinturkey.Thus,we collect information with the consent of our users and consequently, in no account disclose or disseminate the input to other parties excluding our surgeons and medical authorities colllobarating for revitalizeinturkey services. All the input submited are stored in our custmer archives with no access granted to any other personna other than the revitalizeinturkey staff. Disclaimer The information on this Web site is intended to present you to some of the basic facts concerning different surgery/treatments. Its aim is to give you general background information and serve as an introduction to them. The information obtained from this Web site cannot be used to determine whether or not you will have the procedure carried out, nor is it a guarantee of the results or any outcome of the procedure/s you decide to undergo. During the consultations, your surgeon/professional will explain to you in detail how a particular procedure applies to your individual condition. They are for your information only. Individual results may vary. Revitalizeintrkey reminds you that all surgeries carry risks of complications, which in case of cosmetic surgery, include dissatisfaction with the results. Payment Terms The fee quoted will be confirmed after further medical evaluation by the surgeon. Non-Refundable Deposit ( %30 of the total cost ) is required to secure your booking. Deposit can be done in two ways I- Credit Card II- Bank Transfer The deposit paid will deducted from your total balance of payment after arrival. Balance payable directly to TUNÇELLİ Ltd (The officially registered name of revitalizeinturkey ) Payment due can be made via valid Credit C Cost-Estimate For The Surgery The fee quoted will be confirmed after further medical evaluation by the surgeon. It includes, The cost is quoted on all-inclusive basis for the selected procedure: The surgeon, specialist anaesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication, pre and postoperative consultations and non-refundable administration fee. It excludes, Any additional medical expenses for the medications or procedures in case of unforeseen complications.It is crucial that you discuss this with the surgeon before the operation. Cost Estimate For The Services The quotation given is to be confirmed after the pre-surgery/treatment consultation prior to surgery. We will handle an e-mail or telephonic consultation with the surgeon after receiving the medical history form and close up photograph of the body area requested for surgery. The quotation includes, I- The cost is quoted on all-inclusive basis for the selected procedure: The surgeon, specialist anaesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication, pre and postoperative consultations and non-refundable administration fee. II- Pre and Post operative instructions for your selected procedures III-- Accomodation for the required period of time IV-- Personal Assistant to accompany you all your medical appointments and surgery V- Transfers from and to airport (round-way for the airport ), and for the consultation sessions It excludes, I-Transport for all additional venues, II-Daily trips, III-Air ticket to Turkey IV-Any additional medical expenses for the medications or procedures in case of unforeseen complications.It is crucial that you discuss this with the surgeon before the operation. V- The Insurance VI- Other complementary revialization services Please note the prices quoted are subject to exchange rate fluctuations. Certain terms and Conditions apply.Bookings confirmed and not put into effect by the client will be subject to cancellation fees. Medical Examination The quotation initially given is to be further confirmed after the pre-surgery/treatment consultation prior to surgery. Revitalizeinturkey handles the initial consultations via e-mail after receving the medical history form and the clinic or other analysis requested by the surgeon or the medical authority.Revitalizeinturkey encourages you to ask all your questions via e-mail or telephone prior to selected surgery. It is worth indicating that both you and the surgeon/professional are under no obligation until after your pre-operative consultation Revitalizeinturkey reminds you that all kinds of surgery/treatment carry certain risks, whereas the risks associated with cosmetic surgery includes dissatisfaction with the results. You and the surgeon/professional have to agree about the anticipated outcome of your surgery/treatment, so that your expectations of the results will be reasonable. Any medical or surgical advice provided through the revitalizeinturkey web site and service, even if intended to be accurate to the best of our knowledge, should be discussed with the Surgeon. Thus please do not hesitate to consult with our surgeons before deciding to undergo any surgical treatments. If any dispute may arise the surgeon is only liable if litigation takes place in Turkey under Turkish Law. |
|||||||||||