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)
By postal mail:
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.
Title: None Mr. Ms. Mrs. Miss Dr.
|Date Of Birth|
|Company Name (if Applicable)|
|Address 2 (Optional)|
|Facsimile "Fax" Number (Optional)|
Which Executive Physical program are you interested in?
1 2 3
Which tours would you be interested in?
|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|
Please specify nature of Cosmetic Surgery:
Additional Client Services Desired: (please chesk required services)
|Auto Rental||Cellular Phone Rental|
(please name desired hotel):
(how many bedrooms and how long):
|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:
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This page was last updated June 24, 2008
and is located at http://www.internationalmedical.com/commform.html