RegenexxHotelRequestForm2

* Indicates required field

Guest Name *

First

Last

Email *

Phone Number *

Room Type *

Arrival Date 1 (MM/DD/YY) *

Arrival Date 2 (MM/DD/YY) *

Departure Date 1 (MM/DD/YY) *

Departure Date 2 (MM/DD/YY) *

# of Rooms *

Travel Companion *

Additional Comments / Special Requests *

UPON RECEIPT OF THIS FORM, A MEDICAL TRAVEL CONCIERGE WILL PLACE YOUR HOTEL RESERVATION AT SELECTED HOTEL AND 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

Submit

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.