REGENEXXHotelRequest

Medical Travel Concierge - Hotel Reservation Request Form

* Indicates required field

Name ( Legal Name on Drivers License) *

First

Last

Email *

Phone Number *

Hotel Check In Date (MM/DD/YY) *

Hotel Check Out Date (MM/DD/YY) *

Hotel Check In Date 2 (MM/DD/YY) *

Travel Companion *

Hotel Check Out Date 2 (MM/DD/YY) *

Room Type Requested *

Employer *

Date of Birth (MM-DD-YY) *

Departure City *

Procedure Start Date *

Appointment Time *

Preferred Hotel Name: *

Length of Stay *

Getting to the Destination: *

Clinic *

Additional Comments *

UPON RECEIPT OF THIS FORM, A MEDICAL TRAVEL CONCIERGE WILL CREATE YOUR HOTEL RESERVATION AT SELECTED HOTEL AND WILL SEND YOU YOUR CONFIRMATION # AND INSTRUCTIONS TO CONTACT THE HOTEL TO PROVIDE YOUR CREDIT CARD WITHIN 72 HOURS FROM MAKING THE RESERVATION. YOUR RESERVATION WILL BE CANCELLED IF A CREDIT CARD IS NOT PLACED ON THE RESERVATION. IF YOU HAVE ANY QUESTIONS FEEL FREE TO CONTACT US AT (702) 202-2107 OR AT INFO@REGENEXXTRAVEL.COM. BY SUBMITTING A HOTEL RESERVATION REQUEST THROUGH OUR SITE, YOU MUST ABIDE BY THE HOTEL’S CANCELLATION POLICIES. EVENTURE NOR THE MEDICAL FACILITY OR PRACTICE IS FINANCIALLY RESPONSIBLE FOR THE RESERVATION OR ANY OTHER CHARGES ASSOCIATED WITH THE RESERVATION. *

I Understand and Agree to the Above

PAYMENT INFORMATION:
A physical credit card will be required at check-in. If credit card has a different name than guest, a 3rd party authorization form may be required and guest may need to provide additional credit card or deposit for incidentals if authorization does not specify coverage for more than room and tax only.

Submit

COMPANIES

DEAN FOODS PER DIEM

WEBSITES

COMPANY PAY (PAID PER DIEM)

PATIENT PAYS OWN (IPO)

TRAVELER GUIDELINES