Application Form

 

If you would like to apply for a surgery holiday with Gorgeous Getaways, please fill in the following details.

After receiving your form, our team will send you final details for your booking, including:

- surgeon availability / date of surgery

- a quote for your surgery and accommodation. Please send front and side photos to: info@gorgeousgetaways.com

If you would like to apply for a discount towards your surgery holiday, please read here.

Please do not book your airfares until we confirm the date of surgery and prices with you.

Gorgeous Getaways has the right to reject any application due to health or other reasons.

 

 

I would like to apply for a surgery holiday YES
   
What is the name of your GG manager you have been talking to / corresponding with?
   
Your details:  
Your full name
Your Age
Country you live
Email Address


(please note: with Hotmail, Yahoo or AOL accounts, our response to you may be directed to your Bulk folder. Please can you Whitelist "info@gorgeousgetaways.com" in your account, and also specify an alternative account for these addresses)

   
Preferred country/surgeon
(if you are unsure leave blank):

* How to choose the right location and surgeon for you
   
What Surgery Procedures would you like to have:
   

What Non-Surgical Procedures are you interested in- dentistry, skin, beauty, LASIK etc.:
   
Your holiday:  
Number of Adults travelling:*
Number of Children travelling:
Name/s of other people travelling:


Accommodation you would prefer:

(if you are unsure, leave blank)

 
Date of Travel (month if you do not know exact date):
How many days:
Requests for accommodation (eg, queen or twin bed):
   
Your medical details:  
Your height (cm)  
Weight (kgs)  

Your BMI: (height / weight)

To calculate your BMI and for more information on BMI, please click here:

Please note: We cannot accept any patient with a BMI over 30
     
Do you smoke? YES NO
If yes, how many sticks per day?  
If so, would you be willing to quit 4 weeks before surgery? YES NO - Please note that scar problems and risks of surgery are higher for smokers, and for this reason we highly recommend that you quit smoking, including using patches, for at least 4 weeks prior to surgery
 
 
   

Medical Questions:

Have you had, or been treated for any of the following:

 
anemia    YES   NO
asthma    YES   NO
blood clots/deep vein thrombosis    YES   NO
blood pressure    YES   NO
blood disorders    YES   NO
bleeding disorders    YES   NO
breathing problems    YES   NO
diabetes    YES   NO
Hepatitis    YES   NO
AIDS or HIV    YES   NO
epilepsy    YES   NO
heart problems    YES   NO
kidney problems    YES   NO
nose/throat problems    YES   NO
stomach problems    YES   NO
thyroid problems    YES   NO
Are you pregnant or planning to be in the next 6 months?    YES   NO
Do you take the Pill?    YES   NO
If you answered "YES" to any above, can you please detail further: 
Any medical condition or medication not listed? 
Any reactions to local or general anesthetic? 
Any scarring problems? 
Describe your general health - including diet and fitness: 
Have you had psychological counseling or treatment or suffered from depression or drug dependence:    YES   NO
 

If yes, please explain the extent of your treatment and any medications prescribed for this:
Have you had cosmetic surgery before?    YES   NO
 

If yes, please list the procedure you had and the results and if you were happy or not:

Have you ever been rejected for plastic surgery before:    YES   NO
 

If yes, please give details of why you were rejected and by whom:

       
For optical treatments:
Do you currently wear glasses or lenses?    YES   NO
  Please note, for LASIK surgery, you must stop wearing soft lenses for 1 week, or hard lenses for 1 month.
What is your prescription: 
Do you have any problems with your eyes eg. Dry eyes:
   
Other Questions:  
   
What is your motivation for having surgery?
   
How important are your looks to you?
   
How many surgeons have you consulted? What was the reason for not getting this done with them? Have you ever been rejected by any surgeon for cosmetic surgery? Please detail.
   
Have you considered alternatives to cosmetic surgery? What are these and why have you chosen surgery?
   
What would you be happy at achieving with your new look?
   
How are your stress levels? Do you get easily stressed, or do you take changes and events in your stride?
   
What is your pain threshold like?
   
How do you prefer to recover? In privacy, or would you prefer additional support?
   
Have you travelled in Asia before? Are you comfortable with the differences in culture eg. language differences, working culture, times etc., which requires more patience and understanding
   
Are you prepared to help your health in recovery so that risks are lower and results are better eg. give up smoking 4 weeks before and 4 weeks after surgery, stay out of sun, purchase crèmes to help in scar reduction, eat well and exercise.
   
Are you prepared to wait the required time for your final results? This can be from 6 months – 1 year.
   
   
   
   
Please confirm that you have read and agreed to the risks of plastic surgery   YES   NO
   
Please confirm that you have read and agreed to the pre-departure information listing the steps and considerations involved in your cosmetic holiday   YES   NO
   
Did you apply for a discount towards your surgery holiday? (Please refer above)   YES   NO
    
Do you have any final requests or questions?

Thanks for your application. Your manager will send your details to your surgeon and check for availability. We will get back to you with the suitability for your surgery and non-surgical procedures, together with your final quote and date availability.

 
Gorgeous Getaways Pty Ltd ..... Registered ABN: 95107773991 ..... E - info@gorgeousgetaways.com
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