Booking Form - Destination Hospital

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Booking Form

Booking Form

Please complete the booking form below to book your surgery holiday with Hygeia Beauty.

Once you have completed this booking form, we will send you a booking confirmation and invoice (if you want Hygeia Beauty to make your travel arrangements).

Payment for all treatments is made directly to the hospital after your consultation with the surgeon and only after you have decided to go ahead with your treatment.

All fields must be completed before submitting the form.

First Name:
Last Name:
E-mail:
Date of birth (MM.DD.YYYY):
Nationality: :
Passport Number:
I wish to book the following procedures:

Contact address in Thailand:

Time of holiday
Please inform us of your desired time of appointment. If you do not know the exact date yet, please provide an approximate date.

Appointment (MM.DD.YYYY):

Arrival Date (MM.DD.YYYY):
Arrival Time:
Flight Number:

Departure Date (MM.DD.YYYY):
Departure Time:
Flight Number:

For accomulation and tranfer reservations please visit the following website: http://www.destinationbeauty.com/destination/hotels-bangkok-thailand.html

Disclaimer Hygeia Healthcare helps you find medical treatment opportunities abroad. The role of Hygeia Healthcare is to act as a marketing agent for medical facilities and arrange medical treatment packages with the option to include a holiday package. The agreement to have surgery is strictly between the patient and the hospital. The final decision about whether the patient is a candidate for the chosen procedure(s) will be made by the surgeon during the pre-surgery evaluation. Hygeia Healthcare does not offer any medical advice and is in no way liable for the actions of third parties. You are aware of and acknowledge the role of Hygeia Healthcare as described. You further accept that the decision to have medical treatment abroad is your decision and that you are aware of any risks involved.
I have read and understand the disclaimer and agree to the terms specified.

Contact Details:

Hygeia Healthcare
Unit 2 C-D, 2nd Floor Suanplu Corner Building
39/13-16 Soi Suanplu Sathorn Road
Thungmahamek, Sathorn District
Bangkok 10120, Thailand

Phone: + 66 26775662
Fax: + 66 26775663
Phone (From the UK): (+44) 020 8133 8346
Phone (From Denmark): (+45) 36953316
Phone (From USA): (+1) (323) 319-5865
Phone (From Australia): (+61)(02) 8006 2040

E-mail: bookings@destinationhospital.com