*
compulsory fields
First Name*:
Last
Name*:
Age*:
Email*:
(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)
2nd email address if you have one:
Phone:
If
you prefer NOT to be called, please tick here:
Address:
City:
State/Province:
Postcode:
Country*:
Where
did you hear about GG?*
--None--
Internet
search engine
Internet Forum
TV show
Radio station
Newspaper,
magazine article
Friend/Word
of mouth
Advertisement
Other
If you prefer NO email communications
eg. Newsletter, promotions, please tick here:
Your
Surgery Holiday:
Do
you have a Preferred country/surgeon
(if
you are unsure leave blank) :
*
Hints for choosing the right location and surgeon
for you
- Malaysia: Most popular destination/surgeons
- most experienced surgeon/hospital recommended
for all procedures, with proven experience in multiple/combined
treatments.
- Phuket, Thailand: recommended
only for single procedures. Cost effective packages
in a beautiful location.
--None-- No preference - best hospital/surgeon for me
Malaysia: Dr. Jalil, Ampang Puteri Hospital
Malaysia: Dr. Nasir, Prince Court Medical Centre
Malaysia: Dr. Victor, Selangor Medical Centre
Malaysia: Dr. Wong, Promenade Plastic Surgery
Malaysia: Dr. Heng, Columbia Asia Medical Centre
Malaysia: Dr. Eileen Fong, Prince Court Medical Centre
Malaysia: Dr. Lee, Sabah Medical Centre
Sri Lanka: Dr. Dulip, Apollo Hospital
Surgery
Treatments/ Packages:*
We
have discounts for multiple treatments, please scroll
down the list to choose these packages.
Please select a treatment
"Ultimate Makeover" Package
"Beautiful Breasts" - Breast Augmentation
"Fabulous Facelift " Package
"Zap the Fat" - Liposuction Package
Breast Lift or Breast Reduction
Abdominoplasty (Tummy Tuck)
Liposuction to abdomen and chest (men)
Facelift + Liposuction
Facelift + Tummy Tuck
Facelift + Breast Augmentation
Facelift + Breast Aug + Lipo
Facelift + Breast Aug + Tummy Tuck
Facelift + Tummy Tuck + Lipo
Tummy Tuck + Liposuction
Breast Augmentation + Liposuction
Breast Augmentation + Tummy Tuck
Breast Augmentation + Rhinoplasty
Breast Aug + Tummy Tuck + Lipo
If
not on the list above, please list the treatments
that you would like:
Number
of Adults: *
Number of Children:
Name/s of other people travelling:
Accommodation you would prefer:
(if
you are unsure leave blank)
--None-- Malaysia, KL: Crown Princess (4 star)
Malaysia, KL: Lanson Place Apartments (4 star apartments)
Malaysia, KL: Shangri-la KL (5 star)
Malaysia, KL: Warisan Apartments (Homestyle resort)
Malaysia:"Rainforest Recovery"(Lanson Place KL+Sutera Harbour Sabah)
Malaysia:"Rainforest Recovery"(Lanson Place KL+Rasa Ria Sabah)
Malaysia:"Rainforest Recovery"(Shangri-la KL+Sutera Harbour Sabah)
Malaysia, Sabah: "Sabah, Sun & Surgery" Sutera Harbour Resort (5 Star)
Sri Lanka, Colombo: Galle Face (5 star)
Sri Lanka, Colombo: "Beautiful Beach Recovery"
Date
of Travel (month if you do not know exact
date):
How
many days:
--None--
10 days
14 days
21 days
About
yourself (Optional)
Do
you smoke?
--None--
No
Yes, occasionally (<5 ciggs per week)
Yes, regularly (> 5 ciggs per week
Do
you have any health history or problems?
What
are your personal goals for cosmetic surgery?
What
are the factors that are most important for you on
your surgery holiday?
(to select more than
one choice, please select the control (CTRL) key)
Price
Quality
- skilled surgeons and hospitals
Follow
up support and service
A relaxing
holiday
Privacy
Have
you had Cosmetic Surgery before?
Do you have any other questions?
Thanks for your time in filling in this form.
We will respond to your request within 24 hours.