10. Email address (Use personal email. Our emails from Thailand are frequently blocked by IT departments at work locations):
11. Estimated date of surgery:
12. Desired procedure and comments:
** All information will be maintained by Freeland Medical Tours as CONFIDENTIAL data and will not be released to any third party without the individual client's consent. The estimate provided is for planning purposes only and is not an official quote for services to be rendered. Please note that most estimates can be provided in 1 - 2 business days, but some may take as long as 5 - 6 business days, if FMT has to coordinate directly with a specialist. If you have not received a reply within 5 business days, there was probably a problem with the email address you provided. If you provided your work email address, it may have been blocked by the IT department as an overseas email. You may also try lowering the security setting on your antivirus software.
9. Phone (Optional):
Administrative Fee (nonrefundable) $349.
PayPal Payment Selections (Credit Card, Bank Acct, PayPal Acct)
