Medical Travel Concierge
Medical Travel
Destination Concierge
Contact
FAQs
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
*
CHOOSE ONE
Yes
No
Unsure
Hotel Check Out Date 2 (MM/DD/YY)
*
Room Type Requested
*
CHOOSE ONE
KING
TWO QUEENS OR DOUBLES
OTHER
Employer
*
Date of Birth (MM-DD-YY)
*
Departure City
*
Procedure Start Date
*
Appointment Time
*
Preferred Hotel Name:
*
Procedure Type
*
Stem Cell
Platelet
Spine
Consultation Only
Other
Length of Stay
*
Select Approved # Nights
1 Night
2 Nights
3 Nights
4 Nights
5Nights
6 Nights
7 Nights
8 Nights
9 Nights
Other
Getting to the Destination:
*
CHOOSE ONE
Flying
Driving (Staying for all appointments)
Driving (Back and forth each day)
Patient is unsure
Clinic
*
SELECT A REGENEXX CLINIC
Advanced Pain Care and BioHealth Institute (Camp Hill, PA)
Algocells
Algone Interventional Pain Clinic (Wasilla, AK)
AMR Pain & Spine Clinic (St. Louis, MO)
Atlanatic Regenerative Joint & Spine (Jacksonville, FL)
Beacon Orthopedics (Cincinnati, OH)
Bodyworks Musculoskeletal Medicine (Louisville, KY)
Chun Chuan Clinic
Center for Regenerative Orthopedic Medicine (Medford, OR)
Centeno Schultz Clinc (Broomfield,CO)
Chicago Arthritis & Regenerative Medicine (Chicago, IL)
Columbia Pain Management, P.C. (Hood River, OR)
Cutting Edge Integrative Pain Centers (Elkart, IN)
Eastern Idaho Spine, Sports, and Rehab Center (Idaho Falls, ID)
Harbor View Medical (Des Moines, IA)
Interventional Ortho Connecticut (Danbury, CT)
Interventional Orthopedics of Atlanta (Atlanta, GA)
Interventional Orthopedics of Raleigh (Raleigh, NC)
Manzano Medical Group (Albuquerque, NM)
Mountain View Rehabilitation (Grass Valley, CA)
Momenta Pain Clinic (Omaha,NE)
Nepean Specialist Sports Medicine
Nashville Regenerative Orthopedics (Franklin, TN)
Northwest Center for Regenerative Medicine (Spokane, WA)
Nura Clinics (Edina,MN)
Orthopedic Regenerative Medicine (Brussels, Belgium)
Ortho Regenerative (Seatlle, WA)
Pain and Neuropathy Center of PA
ProMedica (Toledo, OH)
Regenerative Orthopedic Medicine (Medford, OR)
Regenerer (Norcross, GA)
Regenexx Cayman (Grand Cayman, KY)
Regenexx Des Moines
Regenexx San Francisco (San Rafael, CA)
Regenexx Kansas City
Regenexx Laguna Hills (Laguna Hills, CA)
Regenexx Las Vegas ( Las Vegas, Nv)
Regenexx Los Angeles/Healthlink Center (Los Angeles /Beverly Hills, CA)
Regenexx Philadelphia (Philadelphia/Horsham,PA)
Regenexx Pittsburgh (Pittsburgh, PA)
Regenexx San Diego (Oceanside, CA)
Regenexx San Francisco
Regenexx Tampa Bay ( TampaBay/Sarasota, FL)
Regenerative Athletic Medicine (Danbury, CT)
Regenerative Medicine & Rehabilitation Of Hawaii
Regenerer (Norcross, GA)
Regenortho Sport (Dallas, TX)
Rehabilitation Center of New Jersey (Wayne, NJ)
Rejuv Medical Clinic (Waite Park, MN)
Rejuv Medical Clinic (Savage, MN)
Restore Orthopedics and Sports Medicine (Sonora, CA)
Restore PDX (Beaverton, OR)
Southern California Orthopedic Institute (Thousand Oaks, CA)
Southern California Orthopedic Institute (Van Nuys, CA)
Stem Cell ARTS/National Spine& Pain (Chevy Chase, MD)
Texas Interventional Orthopedic and Regenerative Medicine (Missouri City, TX)
Total Care (Lafayette, LA)
Tri-state Regenerative OrthCare Institute (Cedar Knoll, NJ)
Vermont Regenerative Medicine (Winooski, VT )
Wasatch Pain Solutions (South Jordan, UT)
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