Communication and Registration Form

Thank you for your interest! Please complete the following and we will have a representative contact you. So that we may better serve you, please include any questions you may have in the "Questions and Comments" section below.

You may complete this form online and email it to us by clicking the Submit button at the bottom of this form when done. Or, please feel free to print this form and fax it or mail it to us as follows:

Phone: 310-435-3302 (for any questions)
Facsimile (fax): 818-591-2713

By postal mail:
International Medical Care, Inc.
11901 Santa Monica Blvd., Suite #550
Los Angeles, CA 90025 USA

International Medical Care will immediately reply to your email, fax or letter with the approximate length of stay and the program rates that specifically meet your needs.

Please complete the Medical Questionnaire as well.

Title:  None  Mr.  Ms.  Mrs.  Miss  Dr.

First Name
Last Name
Date Of Birth
Company Name (if Applicable)
Address 1
Address 2 (Optional)
City
State/Province
Country
Zip/Postal Code
Email Address
Phone Number
Facsimile "Fax" Number (Optional)

Which Executive Physical program are you interested in?
1  2  3

Which tours would you be interested in?

Shopping Tour
Universal Studios Disneyland
LA City Tour Stars' Homes Tour
Knotts Berry Farm San Diego/Tijuana
Sea World Sea World/Tijuana
Universal Studios/LA Tour Universal Studios/ Stars' Homes

Additional Medical Services Desired: (please check required services)

Hair Implants Weight Loss Program
Rehabilitation Program Laser Vision Correction
Cosmetic Surgery

Please specify nature of Cosmetic Surgery:

Additional Client Services Desired: (please chesk required services)

Auto Rental Cellular Phone Rental

Accomodations

Hotel
(please name desired hotel):
Apartment Rental
(how many bedrooms and how long):
Other Arrangements
(please detail):
How many adult companions
and/or family members?:
How many children?:
Anticipated date of arrival?:

Mode of payment: Check  Credit Card  Cash  Bank (wire) Transfer

Questions and Comments:

Thank You for completing the information above. Clicking the "Submit Form Now"button below will email us your information and return a confirmation to your browser. After reviewing the confirmation, click the "Back" button on your browser to return to the previously viewed page.

Clicking the "Clear Form Contents" button will cause all information you typed in the above form to be cleared (removed), and the form will be reset to default values. Clicking on "Index" below will return you to our home page and will not submit the above form.

   

Copyright © 1998, International Medical Care, Inc.

Email comments and suggestions to EMAILIMC @AOL.COM


This page was last updated June 24, 2008
and is located at https://www.internationalmedical.com/commform.html