Healthcare Trip









Note: All fields in Sections 1, 2, 3 and 6 are required.

INQUIRY FORM

Your Name

  1. PERSONAL DETAILS

 

1.1 Patient’s Full Name

1.2 Gender

1.3 Date of Birth

1.4 Age

1.5 Country

  1. CONTACT DETAILS

 

2.1    Email address

2.2 Cell Phone number

2.3 Home address

2.4 Occupation

2.5 Phone number

2.6 Work address

  1. YOUR MEDICAL INQUIRY

 

3.1 Are you interested in any of our proposals?

 

* Please attach at least two (2) photos of your current condition (where applies)

3.2 Required medical procedure 

3.3 Present medical/health condition *

3.4 Provide details in relation to your inquiry

3.5 Estimate the cost of the medical procedure?

From €    To €

3.6 Which are your post-procedure expectations?

  1. PLANNING YOUR TRIP

Select/complete the fields of services you are interested for.

4.1 Air ticket

  • Yes
  •  No

If Yes, please compete:

Dates:

Country & City:   
From/To (please indicate origin/return airport):

4.2 Accommodation

  • Yes 
  • No

 

 

If you are travelling with companion(s), please complete section 4.4.

If Yes, please select:

  • Single Room  
  • Double Room *
  • Private accommodation

Category of hotel or type of property: 

  • 3* hotel
  • 4* hotel
  • 5* hotel
  • Private accommodation
  • Other:

Duration of Stay:  (nights)

 

Dates:

 

Basis

  • Bed & breakfast
  • Half Board
  • Full Board
  • All inclusive

 

4.3 Airport transfers (return: airport-hotel-airport)

  • Yes          
  • No

If Yes, please select:

  • Private car/taxi
  • Private mini-van (6 seats)
  • Wheelchair accessible vehicle
  • Luxury Limousine

4.4 Number of companions: …..  / Full Names: 

1.

2.

3.

Relation

1.

2.

3.

Accommodation

Sharing a double room (with patient)

Single room

Other:

  1. Estimate the cost of all the above services selected (for all participants): € (please complete)
  1. Where did you find us?

(please complete)

 

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NEWS
Thank You!
for your trust, cooperation and support!
FNL CUP 2018 IN CYPRUS
FNL CUP 2018, CYPRUS 10 - 23 February 2018 PAPHOS
FNL CUP 2017
FNL CUP 2017, CYPRUS 11 - 24 February 2017 LARNAKA
MAIN OFFICE ADDRESS:

Feel free to contact with us

Arch. Makariou III 20, Eleneio Bulding,
Shop 3, 6017 Larnaca, Cyprus

P.O.Box: 40399, 6303 Larnaca, Cyprus

Tel:(357) 24 659706
Fax:(357) 24654502
24 hours contact: (357) 99 356998

e-mail: info@tecomaservices.com.cy
ABOUT OUR COMPANY


Tecoma Services Limited has been formed in 2009 and begun its official operations in June 2010.