Client Information Form Toll Fre

Contacts First Name
Contacts Last Name
Email Address
Email Address Again:
Patients First & Last Name (if different than above)
Relationship if contact is not patient
Address
City
State/Province	Zip/Postal Code
Country
Daytime Phone
Evening Phone
Best time to contact you by phone
How did you find our Site ?	If other, specify
Has patient ever been out of the country for Medical Care	Where & When
Are you from a foreign country, or is there a country or countries that you would prefer ?
What medical or surgical condition are you requesting information on?	other
When should treatment begin?
Do you need financial assistance for this procedures .	Age Weigh Height
Are you currently being treated for this or any disease. List any medications that you are taking .
Specify procedure that you are seeking .
What is your current state of health, If you have been suffering from a prolonged disease or condition, how long, when did it start, what treatments have you had. The more information we have, the better we are able. to assist you.. .
Please provide any additional information that we should know to help us connect you with the the most experienced Physicians and/or Surgeons.
Are you now, or have you ever worked with another Medical Tourism Company

For Security, please enter the word ~~Save~~

Info@GlobalSurgeryProviders.com

Note: Your information is held within a secure server that we manage ourselves. It will never be sold or distributed to anyone under any circumstances. We are not medical providers... we are Medical Tour Operators, and it is our role to put you in direct contact with some of the most qualified Surgeons and Physicians in the world, practicing at JCI Accredited Hospitals that are all rated equal to, or better than medical facilities in the USA... and save you up to 70% in the process.

Once YOU have interviewed and selected the overseas provider that you are comfortable working with, we then organize all of the details involved in that trip. Flights, accommodation, transportation, meals, sightseeing, around your medical procedure, and assure that all pre-surgery, surgery, and post surgical requirements are performed perfectly. The procedure is only one component of traveling out of the country... pre and post surgical care, along with rehabilitation and follow-up are equally (or sometimes even more) important than having a successful procedure, and Global Surgery Providers makes sure that every detail is taken care of perfectly so that you return having had an overall exceptional experience !
This is what we do...

International Medical and Surgical Procedure, Serving Medical Tourism Patients with Savings up to 70%

International Surgical Procedures Costa Rica overseas surgery saving 70% quality surgeons and world class medical facilities - Global Surgery Network voted # 1
Copyright (c) 2009 Global Surgery Providers, Inc. All rights reserved. | Privacy Policy g