CANCER TREATMENT

PATIENT DEMANDS

Your Name	:
Your Surname	:
Company Name	:
Sector	:
Your position in the field of business	:
Telephone	:
E-Mail	:
Web	:
Address	:
Country	:
City	:
Age	:
Are you a Health Tourism broker?	:	Yes No
If not, indicate the total number of people to participate in your own health trip (members of family, your friends). If you are a broker, indicate total number of people you will bring.	:
Will there be any companions?	:	Yes No
If yes, how many?	:
Which treatment, surgical operation do you consider? Please indicate.	:
What is the planned date of your trip to Turkey?	:
Your flight preference?	:	Economy Business First Class
Your hotel preference. Please indicate the number of stars for the hotel.	:	3 4 5
Do you require collection from the airport?	:	Yes No
Do you request VIP service at the airport?	:	Yes No
Do you want to benefit from the tour and/or holiday packages for you and your family in the city you will receive health service?	:	Yes No
Health Insurance	:
Centers on which you would like to receive more detailed information	:
Message	:

Please send your health reports to us by fax (0090 352 221 42 45) or e-mail (gul@healthtourism.com.tr).


	First Health Tourism Coordinator ICC-T ULUSLARARASI ORTAK BİLİNÇ AJANS A.Ş. G.Nesibe Mh. Tekin Sk. Hukuk Plaza No:6 Kocasinan / Kayseri / TURKEY Tel:009 0352 221 42 48 - Faks: 009 0352 221 42 45 www.icc-t.com \| ajans@icc-t.com