Applicant’s Name
Age
Email address
Phone number
Travel Dates from: to:
Name of tour facilitator
Name of accommodation provider
Details of condition being treated
Details of procedure to be performed
Scheduled procedure date
Facility where treatment will be performed
Name of treating practitioner
Cost of procedure
Nature and dates of follow-up treatment
Name
Address
Have you consulted this practitioner in respect of the abovenoted condition? yes no
If yes, does this practitioner recommend the procedure noted above? Yes No
Is this practitioner aware that you are travelling overseas to receive treatment? Yes No
Have you discussed the likely success of the procedure with this practitioner? Yes No
If yes, what advice / recommendations did this practitioner provide?
Have you had any previous treatment for the abovenoted condition? Yes No
If yes, please provide details
Have you previously had any other elective and / or cosmetic dental procedures? Yes No
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