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By completing the form below you can order a travel arrangement with International Health Care. It is simple, and within 2 working days, you will receive an order confirmation. If we need any extra information, we will contact you by email or phone before completion of your order. Therefore you should always take your time to ensure, that you have entered all information requested in your order form.

Please notice: When booking eye surgical travels, you must always enter your visual acuity to ensure, that we are able to decide if the patient is suitable for the treatment, which has been requested.

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Blanks marked with * are compulsory!

Type of Surgery:*

First name:*
As in your passport

Surname:*
As in your passport

Address:*

Postcode & City:*
E.g. 1620 Copenhagen W

Date of Birth:*
E.g. 27.06 1957

Telephone no.:*

Mobile no.:

E-mail:*
Make sure to type in your correct e-mail address!

Supplementary Treatments:

Departure Date:*

Travel Length:
E.g. 4 days

Departure From:*

(Vision):

Number of Fellow Travellers:*
E.g. 0

(Discount Code):

Comments:
NOTE: All possible fellow travellers data (name as in their passport and date of birth) has to be filled out in this blank

Where have you heard of us?
E.g. recommendation from a friend, advertisement on webpage, seen on TV etc.

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