Deep South Vitrectomy Recovery Booking Form

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Email *

Customer name: (firstname lastname) *

Best phone number (403-555-1212) *

Street Address: *

Town or City *

Postal Code *

First date you require vitrectomy recovery package. *

YYYY

How many weeks would you like to book for?
You may cancel additional weeks at any time for a full refund. Partial weeks will be prorated. *

I understand the only form of payment accepted is cash or Interac e-transfer. e-Transfers must be sent to deepsouthvr@gmail.com. A non-refundable $100 deposit is required for all advance bookings. *

I understand.

I understand a valid credit card and photo ID is required at the time of booking. There are for security purposes only. *

I understand.

A receipt will be provided to the email address above if requested.
*

Yes I understand and the email and physical addresses above are correct.

I don't need a receipt.

Other:

Required

A copy of your responses will be emailed to the address you provided.

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