Surgeon and Safari - Booking Form

IT IS IMPORTANT TO READ, UNDERSTAND AND AGREE TO OUR
TERMS AND CONDITIONS BELOW
Terms & Conditions ------------------------------ -------------------------------------- Surgical Recuperation Accommodation -------------------------------------- "Privacy in Paradise"; - where you can cocoon and emerge after spending time in luxurious surroundings, making your recuperation process comfortable and memorable. You will be met at the International Airport and accompanied to all your medical appointments whilst being transported in your own private vehicle to ensure your privacy. We look forward to welcoming you and assure you of our best care and attention at all times. If you have any queries or require any further assistance, please do not hesitate to contact us. Cost Estimate: -------------------------------------- The cost estimate for recuperation is quoted in SA Rand and subject to exchange rate fluctuations. Certain terms and Conditions apply. Any bookings confirmed and not taken up will be subject to cancellation fees. Includes: -------------------------------------- Accommodation Personal Assistant (A friend away from home) to accompany you to all your medical appointments and surgery Transport for return airport transfers and medical appointments. Detailed Itinerary. Excludes: -------------------------------------- Rejuvenation treatment. Transport for all additional outings. Safaris Options. Additional expenses not specified. 1% Government Tourism Levy and 14% VAT. Meals ( Depending on the type accommodation choice ). Return air ticket to South Africa. Payment Terms: -------------------------------------- Non-Refundable Deposit required securing your booking. Deposit to be invoiced and paid to Surgeon and Safari via bank Transfer - as indicated on the invoice - and will be deducted from the daily room rate charged. Balance payable when you check out on departure. Payment can be made via valid Credit Card or Travellers Cheque. -------------------------------------- Surgery - Terms and Conditions -------------------------------------- Medical Evaluation: -------------------------------------- The fee quoted will be confirmed after further medical evaluation by the surgeon. We will arrange a telephonic consultation with the surgeon after receiving the medical history form and close up photograph of the body area requested for surgery. (Plastic surgery and orthopaedic surgery). We encourage you to ask questions using email or the telephone and will put you in touch with past clients as we believe that you need to make an educated choice. Both you and the surgeon are under no obligation until after your pre operative consultation. Surgeon & Safari remind you that all cosmetic surgery carries a risk, has limitations which could include disappointment with the results. You should agree about the anticipated outcome of your surgery and concur about your expectations of the results. You should discuss alternative treatments and thoroughly understand the risk of the procedures If any dispute may arise the surgeon is only liable if litigation takes place in South Africa, under South African Law. Any medical or surgical advice provided through the Surgeon & Safari web site and service, even if intended to be accurate to the best of our knowledge, should be discussed with the Surgeon. Always seek advice from your Surgeon before embarking on any treatment, medication or therapy. Cost Estimate - Surgery: -------------------------------------- The cost estimate is to be confirmed by the surgeon at your pre op consultation prior to surgery. The cost estimate is subject to exchange rate fluctuations, Certain terms and Conditions apply Includes: -------------------------------------- The cost is all-inclusive whilst in South Africa for selected procedure: The surgeon, specialist anaesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication, pre and postoperative consultations and non-refundable administration fee, for the selected procedures. Medical evaluation & Email correspondence and Telephonic consultations. Pre and Post operative instructions for your selected procedures. Detailed Itinerary for pre and post operative consultations. Excludes: -------------------------------------- Any additional medical expenses that might have incurred for the safety of your health as a result of unforeseen complications &mdash please discuss with the surgeon. Insurance. Additional procedures. Payment Terms: -------------------------------------- Non Refundable Administration Fee charged as a deposit to secure your booking. Deposit payable to Surgeon & Safari via bank transfer as indicated on the invoice & and will be deducted from the agreed cost estimate. Balance of the fee payable directly to the surgeon at your pre operative consultation &mdash Payment can be made via valid Credit Card orTravellers Cheque.

Name
Surname
Date of Birth
Postal Address
Country
Email Address
Telephone
Next of Kin: Name and Contact Details
Are you willing to be a reference for future clients?	Yes No
Have you read, understood and agree to the Procedure consent?	Yes No

Flight Details
Insurance It is strongly recommended that you take out comprehensive travel insurance when buying your airline ticket including full medical cover, cancellation and curtailment cover
Arrival: Date
Time
Airline
Flight No

Departure: Date
Time
Airline
Flight no

Surgery
Name of Surgeon
Procedures
Date of Surgery
Have you read and understood the Procedure consent?	Yes No

Surgical Recuperation
Would you like an early check in and late check out - additional days rate	Yes No
Accommodation Venue
Total number of days
Smoking or Non-Smoking
Size of Bed

Meals and Refreshments
Dietary requirements
Types of food

Safari
Name the safari options of your choice
Total number of Safari days

IT IS IMPORTANT TO READ, UNDERSTAND AND AGREE TO OUR TERMS AND CONDITIONS BELOW Terms & Conditions ------------------------------ -------------------------------------- Surgical Recuperation Accommodation -------------------------------------- "Privacy in Paradise"; - where you can cocoon and emerge after spending time in luxurious surroundings, making your recuperation process comfortable and memorable. You will be met at the International Airport and accompanied to all your medical appointments whilst being transported in your own private vehicle to ensure your privacy. We look forward to welcoming you and assure you of our best care and attention at all times. If you have any queries or require any further assistance, please do not hesitate to contact us. Cost Estimate: -------------------------------------- The cost estimate for recuperation is quoted in SA Rand and subject to exchange rate fluctuations. Certain terms and Conditions apply. Any bookings confirmed and not taken up will be subject to cancellation fees. Includes: -------------------------------------- Accommodation Personal Assistant (A friend away from home) to accompany you to all your medical appointments and surgery Transport for return airport transfers and medical appointments. Detailed Itinerary. Excludes: -------------------------------------- Rejuvenation treatment. Transport for all additional outings. Safaris Options. Additional expenses not specified. 1% Government Tourism Levy and 14% VAT. Meals ( Depending on the type accommodation choice ). Return air ticket to South Africa. Payment Terms: -------------------------------------- Non-Refundable Deposit required securing your booking. Deposit to be invoiced and paid to Surgeon and Safari via bank Transfer - as indicated on the invoice - and will be deducted from the daily room rate charged. Balance payable when you check out on departure. Payment can be made via valid Credit Card or Travellers Cheque. -------------------------------------- Surgery - Terms and Conditions -------------------------------------- Medical Evaluation: -------------------------------------- The fee quoted will be confirmed after further medical evaluation by the surgeon. We will arrange a telephonic consultation with the surgeon after receiving the medical history form and close up photograph of the body area requested for surgery. (Plastic surgery and orthopaedic surgery). We encourage you to ask questions using email or the telephone and will put you in touch with past clients as we believe that you need to make an educated choice. Both you and the surgeon are under no obligation until after your pre operative consultation. Surgeon & Safari remind you that all cosmetic surgery carries a risk, has limitations which could include disappointment with the results. You should agree about the anticipated outcome of your surgery and concur about your expectations of the results. You should discuss alternative treatments and thoroughly understand the risk of the procedures If any dispute may arise the surgeon is only liable if litigation takes place in South Africa, under South African Law. Any medical or surgical advice provided through the Surgeon & Safari web site and service, even if intended to be accurate to the best of our knowledge, should be discussed with the Surgeon. Always seek advice from your Surgeon before embarking on any treatment, medication or therapy. Cost Estimate - Surgery: -------------------------------------- The cost estimate is to be confirmed by the surgeon at your pre op consultation prior to surgery. The cost estimate is subject to exchange rate fluctuations, Certain terms and Conditions apply Includes: -------------------------------------- The cost is all-inclusive whilst in South Africa for selected procedure: The surgeon, specialist anaesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication, pre and postoperative consultations and non-refundable administration fee, for the selected procedures. Medical evaluation & Email correspondence and Telephonic consultations. Pre and Post operative instructions for your selected procedures. Detailed Itinerary for pre and post operative consultations. Excludes: -------------------------------------- Any additional medical expenses that might have incurred for the safety of your health as a result of unforeseen complications &mdash please discuss with the surgeon. Insurance. Additional procedures. Payment Terms: -------------------------------------- Non Refundable Administration Fee charged as a deposit to secure your booking. Deposit payable to Surgeon & Safari via bank transfer as indicated on the invoice & and will be deducted from the agreed cost estimate. Balance of the fee payable directly to the surgeon at your pre operative consultation &mdash Payment can be made via valid Credit Card orTravellers Cheque.
I have read, understood and agree to the terms and conditions above	Yes No
IT IS EQUALLY IMPORTANT TO READ THE TRAVEL PRECAUTIONS AND PRE OPERATIVE REQUIREMENTS
I have read, understood and agree to the facts sheet above	Yes No
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