Reservation Form

Please fill out our secure online reservation request form. The contents of the form will be electronically transmitted to us through secure networks and will expedite your reservation process.

Guest First Name: *
 Guest Last Name: *
 Phone Number: *
 Can we leave a message? *
Arrival Date: *
 Type of Surgical Procedure(s): *
 Surgeon's Name: *
 Surgeon's Office Number:
Procedure Address:
Procedure City:
Procedure State:
Zip Code:

Payment Information


Please select the appropriate box:

My recovery package is courtesy of my physician & no payment is due at this time. I understand that on arrival, a credit card will be requested and held on retainer for any additional services requested during my stay, that are not already included in my recovery package (e.g. a la carte menu items, additional spa services, long-distance phone calls, pay-per-view movies, parking, etc.)

My recovery package is courtesy of my physician & no payment is due at this time. For my convenience, I request pre-authorization of the below credit card and desire any services requested during my stay, that are not already included in my recovery package (e.g. a la carte menu items, additional spa services, long-distance phone calls, pay-per-view movies, parking, etc.) to be billed to this credit card during my stay.

I am the responsible payer of my recovery package. I wish to hold my reservations with a $200 deposit applied to the below credit card & understand that the balance due on my recovery package will be applied 48-hrs prior to my stay. In addition, I understand that any additional services requested during my stay, that are not already included in my recovery package will be billed to this credit card.


Credit Card Information
Select a Credit Card: *
 Credit Card Number: *
 Expiration Date: *
 Card Security Code: *
First Name: *
 Last Name: *
    
Address: *
 City: *
 State: *
 Zip Code: *

If you wish to use cash, check or financing for the remainder of your bill, call us @ 614-580-9395 for details.

Please note that any additional charges incurred during your stay or outstanding balances will automatically be billed to your above credit card. Additional charges may include, but are not limited to medical supplies, mileage adjustments, parking, long-distance phone calls, pay-per-view movies, internet access, a la carte menu items and any additional services requested during your stay that are not already included in your recovery package.