Medi Makeovers
Zetland, New South Wales Australia
Email: daniela@medimakeovers.com | Website: https://medimakeovers.com/
Phone: 61416109417

International Medical Travel Services and Insurance Enrollment Application

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Thank you for your interest in Insurance and Services for your medical tourism travel. GPS provides services and insurance designed to meet the needs of the medical traveller / medical tourist and can include traveling companion(s). Complete the below to get pricing and enrollment instructions for travel accident and medical complication insurance specifically designed for those who are undergoing elective medical or dental procedure(s) outside their country of residence.
Frequently Asked Questions

All insurance costs and enrollment limits are indicated in ($) US Dollars.

First / Given Name

Last Name / Surname

Date of Birth

Age limits for benefits and services is age 70 or younger

Re-Enter Your Email

Country of Citizenship

Country of Residence

Destination Country

Depart Date

Procedure Date

Return Date

If you have a Case Manager or Facilitator that is assisting in arranging your travel and medical needs, please name the Company in the below space.
Otherwise, if you are not using a provider of such services, please type "None" in the below space.

Hospital / Facility Name

Hospital / Facility City (Enter ONLY City)

Hospital / Facility Country -

Is the Hospital / Facility Eligible?

Yes No ( Please define )

A qualifying medical facility: means a hospital, clinic or place for medical, surgical or dental treatment duly qualified by the jurisdiction where the facility is located, and/or possessing an international accreditation from an ISQua member organization or other recognized international accreditation body.

International Society for Quality in Health Care (ISQua)

Covid Coverage

Covid coverage is available at a separate limit of $25,000.00 for illness and $5,000.00 for travel meals and accomodations.
The cost is $72.00 per person. To be eligible for benefits, please see requirements here:
Insured Requirements/Exclusions

A SARS-CoV-2 (COVID-19) must be initially diagnosed after the insurance departure/effective date.
Insured to follow ALL protocols, laws, directives, curfews as provided by host country
If at any time before travel there is the wide availability of an inoculation or vaccine to protect against SARS-CoV-2 and it mutations, the Insured must receive such vaccine before departure.

Do not include COVID Coverage.
Elect Coverage: $25,000.00 - Included for enrolled insured and companion(s)

Please list all of the likely procedures / treatments you may receive. Give accurate and detailed information.

I decline home country coverage.

Initials

Referral/Other Explanation

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