Patient Name

LCMI Patient Yes    No

Age

Nationality

Date of Arrival in the Philippines

Date of Departure

Contact Information

Accompanying Person

Mode of Payment Cash    Visa    Mastercard

Surgical Procedure

Kind of Anesthesia Local    Sedation    General

Preffered Hospital Beverly Hills Medical Group
Manila Doctors Hospital
The Medical City

Preffered Room Accomodation Suite Room    Deluxe Room

Booking Deposit 10% of Total Expenses(Non-Refundable)

Medical History submitted Yes    No

Medical Clearance Yes    No