The SurgicalEscape Process:

1. Call SurgicalEscape at 1-866-205-8855 or visit us online at:
    http://www.surgicalescape.com

2. Complete the information forms.

3. A SurgicalEscape representative will follow up with you and provide a
    quotation for your package.

4. Complete your personal medical questionnaire which will be sent to you via
    email. If necessary, we may require X-rays or MRI’s.

5. A conference call will be arranged between you and your physician abroad
    who will answer all your medical questions.

6. Finalize your procedures and trip itinerary.

7. Full payment will be collected for your package,

8. Depart for your chosen destination/hospital.

9. Greeted by your SurgicalEscape representative at the airport who will assist
    you through customs and take you to your accommodations.

10. Meet your doctor for the initial consultation.

11. Your procedure will then take place.

12. Recuperate and relax at your retreat with VIP service and care.

13. Participate in any tours that may you have selected.

14. Travel home.

15. Your physician and SurgicalEscape representative will call to follow-up.

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Title:	---- Select ---- Dr. Mr. Mrs. Miss. Ms.
Full Name:*
Email: *
Phone: *
Principal Interest:	---- Select ---- None in Particular Cosmetic & Plastic Surgery Bariatric Surgery Orthopedics Dentistry Ophtalmology Medical Check Ups Dermatology Cardiology Neurosurgery Gyn/Ob Surgery General IVF
Specific Procedure:
Second Interest:	---- Select ---- None in Particular Cosmetic & Plastic Surgery Bariatric Surgery Orthopedics Dentistry Ophtalmology Medical Check Ups Dermatology Cardiology Neurosurgery Gyn/Ob Surgery General IVF
Specific Procedure:
Country Interested for Procedure:	---- Select ---- Costa Rica Barbados Mexico
Surgery Timeline:	---- Select ---- 1-2 months 2-4 months 4-6 months Doesn't Matter
Address:
City:
Province/State:
Postal Code :
Country: *
Message: *

Please review and make corrections in the above form before submitting.
* Information must be completed.