Reception Form

Name:

Surname :

Age :

Email :

Mobile number :

Country:

City:

Address:

Passport no :

Passport date of issue:

Passport date of expiry:

The needed surgery :

If the needed surgery or above information need more explanation

Upload image or file :

Needed touristic services :

Hotel :

Number of room :

Number of bed :

Transfer services:

Date of travel :

Month:

Depart:

Return:

How do you pay?

Notice:

1-The rest of package price must be deposited into Abnoos Company account at least one day before being hospitalized.
2-The full price is according to the usual length of stay in hospital and hotel which are mentioned in the packages.It is obvious that the margin will be received if the length of stay increases.

I agree and confirm the above information