Promotion Booking Form

Please complete the following form for your holiday and treatments. Please give as much information as possible in all cases, especially your health and medical history.

All bookings must be accompanied by payment for accommodation, which can be paid by credit card or direct transfer. Payment for all surgery and dentistry treatments is required only after the consultation with the surgeon, when you are happy and agree to go ahead.

Your name:
Age:
Address:
Country:
Telephone:
Mobile:
Email:  
 

Where did you hear about Gorgeous Getaways?


HOLIDAY BOOKING:

I would like to book the following promotion package:

"Beautiful Breasts" - Breast lift/Breast Augmentation

"Zap the Fat" - Liposuction

"Fabulous after Forty" - Full Facial Rejuvenation

 
Would you like to book any other procedures - dentistry, LASIK, pampering etc:

Date of booking:

How many adults/children (under 12): Adults: Children:

Do you have any special dietary requirements?:

Your flight details (name of airline, arrival date and flight number):

Arrival flight:

Departure flight:

 
 

 

MEDICAL QUESTIONS:

Your height (feet or cm)  
Weight (pounds or kgs)  
Do you smoke? YES NO
If so, would you be willing to quit 3 weeks before surgery? YES NO
 
Have you had, or been treated for any of the following: (Please check YES or NO)
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
psychiatric illness   YES   NO
depression   YES   NO
drug dependence   YES   NO
Are you pregnant?   YES   NO
Do you take the Pill?   YES   NO
If you answered "YES" to any above, can you please detail further:
Any condition not listed?
Any medication not listed?
Any reactions to local or general anesthetic?
Any scarring problems?
How would you describe your general health - including diet and fitness?
Please describe your personal goals for surgery/holiday:
Have you had cosmetic surgery previously?   YES   NO

If YES, please describe the surgery you have had and the outcome:
       
For optical treatments:
Do you currently wear glasses?   YES   NO
What is your prescription:
Do you have any problems with your eyes eg. Dry eyes:

If you haven't already, please provide photos to: info@gorgeousgetaways.com

Next Step: Read and agree with the Terms and Conditions of Booking

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