Surgeon and Safari - Cosmetic Surgery History Form

IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW

Terms & Conditions ------------------------------ Â -------------------------------------- Surgical Recuperation Accommodation Package -------------------------------------- Â Surgeon and SafariÂ has its own unique private home situated in an up market residential area, offering private rooms in both a main house and a separate cottage, allowing the time to rest and healÂ in a truly comfortable yet personalized home from home, with experienced staff ( living on the property ) taking care of pre and post operative needs offering an environment of wellness. Â All rooms are private en suites offering privacy if needed: Beds have quality bed linen and non allergic down pillows and duvet Rooms have standard in room amenities ( hand creams, shampoo ) together with specialized post surgery amenities. Â Â Cost Estimate: -------------------------------------- The cost estimate for recuperation is quoted in SA Rand and subject to exchange rate fluctuations. Certain terms and Conditions apply. Â Â Includes: -------------------------------------- Accommodation Package Room - 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 - scheduling travel, booking medical appointments SupportÂ andÂ assistanceÂ before and during recuperationÂ with full medical concierges services - Hospital admission and discharge Meals Laundry Refreshments Â Excludes: -------------------------------------- Â·Â Â Â Â Â Â Â Â Professional tour guidesÂ are available. Â·Â Â Â Â Â Â Â Â Shopping trips arranged when needed.Â Â·Â Â Â Â Â Â Â Â Thai Massage and Reflexology offered in room during recuperation Â·Â Â Â Â Â Â Â Â Fruit Acid Peels offered in room during recuperation Â·Â Â Â Â Â Â Â Â Arrange appointments for hairdresserÂ and other beauty treatments . Safaris Options. Additional expenses not specified. Return air ticket to South Africa. Â Payment Terms: -------------------------------------- Payment for Accommodation Package to be made in full as per Pro Forma Invoice and paid to Surgeon and Safari via bank Transfer in order to confirm accommodation and services Any changes made after confirmation of your booking will be rescheduled if needed and / or adjusted and refunded accordingly Any bookings confirmed and not taken up will be subject to cancellation fees. Â Â -------------------------------------- Surgery - -------------------------------------- Please note that your decision to proceed with surgery will be made in consultation between yourself and your selected surgeon Surgeon and Safari is a facilitation company and offers you a full medical concierges service and are not qualified to make any medical comment nor offer medical advice or suggested treatment / procedures, these need to be discussed with your surgeon. Â Medical Evaluation: -------------------------------------- The fee quoted by Surgeon and Safari will be confirmed after further medical evaluation by the surgeon based on the medical history and requirements forwarded by yourself as requested and forwarded to the Surgeon After medical feedback from the surgeon we will be glad arrange a telephonic consultation with the surgeon prior to making a decision regards to your travel 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. Â Terms 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 or agreeing to any surgery. Â 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 Â Includes: -------------------------------------- The cost is all-inclusive whilst in South Africa for selected procedure: The surgeon, specialist anesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication whilst in hospital, pre and postoperative consultations in South Africa 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. Â Excludes: -------------------------------------- Any additional medical expenses that might have incurred for the safety of your health as a result of unforeseen complications Ã� please discuss with the surgeon. Insurance. Additional procedures. Â 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 pro forma invoice and will be deducted from the final account payable to the surgeon. Balance of the fee payable directly to the surgeon at your pre operative consultation Payment can be made in Cash or via valid Visa, Master and Amex Credit Card Any changes made to booked medical procedures which affect the costs initially quoted and / or paid will be reconciled, adjusted and payable or refunded with your final Surgeon Account If for any medical or unforeseen circumstances your surgery needs to be cancelled the costs paid will be reconciled, adjusted and refunded accordingly.

Name
Surname
Date of Birth
Weight and Height	W H
Postal Address
Country
Telephone
Fax
Email Address
Occupation
Hobbies and Interests and sport
Selected Surgical Procedure
Why are you considering this procedure?
If you are currently consulting a Psychiatrist or Psychologist Have you discussed your intention of having the above mentioned surgery	Yes No
Have you ever been treated for psychiatric illness? This includes depression. If so, what treatment have you been on in terms of anti-depressants, sleeping tablets, anxiolytics (anti anxiety) How long have you been taking this treatment?	Yes No
Would it be possible to get a comprehensive report from your physician/psychiatrist in terms of your condition?	Yes No
Have you suffered from previous deep vein thrombosis, i.e. blood clots, developing in the leg following long air flights, long hospital stays, etc? If so, when was this and what treatment were you prescribed and for how long	Yes No
Have you ever abused drugs or any substance? If so, What and for how long and when did you stop.	Yes No
Current and prescribed Medication you are taking
Past Medical History that needs mention

Allergies
What are your concerns, worries and fear about having this procedure
What is it that you do not like about yourself? - Please explain
Have you consulted a surgeon for this procedure? If so, what was the plastic surgeon name and what was his plan of operation?
Do you drink or smoke? Give Details	Yes No Cigarettes / Day Drinks / Day
Have you or your family ever had difficulties with General Anaesthetic? If so, please advise of any complications.	Yes No
Are you prone to KELIODS or poor scaring?	Yes No
Have you ever been ANAEMIC? If so, how was it treated and have you ever had a Blood Transfusion?	Yes No
If a blood transfusion should be necessary, would there be any reasons at all why you would refuse it?
Do you have ASTHMA or LUNG DISEASE?	ASTHMA Yes No LUNG DISEASE Yes No
Do you have HIGH BLOOD PRESSURE? If so, what treatment are you taking and are you well controlled?	Yes No
Do you have any known HEART problems?	Yes No
Have you ever been JAUNDICED?	Yes No
Are you on the "PILL" or any other HORMONE?	Yes No
Do you or any relatives have DIABETES? If so, please specify	Yes No
Please name the surgeon you have selected
When would you consider travelling to South Africa?
Would you like to correspond with past clients?	Yes No
Would you like to have a consultation in London Please look at the London consultation calendar	Yes No
If YES, specify the dates for the London consultation
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW Terms & Conditions ------------------------------ Â -------------------------------------- Surgical Recuperation Accommodation Package -------------------------------------- Â Surgeon and SafariÂ has its own unique private home situated in an up market residential area, offering private rooms in both a main house and a separate cottage, allowing the time to rest and healÂ in a truly comfortable yet personalized home from home, with experienced staff ( living on the property ) taking care of pre and post operative needs offering an environment of wellness. Â All rooms are private en suites offering privacy if needed: Beds have quality bed linen and non allergic down pillows and duvet Rooms have standard in room amenities ( hand creams, shampoo ) together with specialized post surgery amenities. Â Â Cost Estimate: -------------------------------------- The cost estimate for recuperation is quoted in SA Rand and subject to exchange rate fluctuations. Certain terms and Conditions apply. Â Â Includes: -------------------------------------- Accommodation Package Room - 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 - scheduling travel, booking medical appointments SupportÂ andÂ assistanceÂ before and during recuperationÂ with full medical concierges services - Hospital admission and discharge Meals Laundry Refreshments Â Excludes: -------------------------------------- Â·Â Â Â Â Â Â Â Â Professional tour guidesÂ are available. Â·Â Â Â Â Â Â Â Â Shopping trips arranged when needed.Â Â·Â Â Â Â Â Â Â Â Thai Massage and Reflexology offered in room during recuperation Â·Â Â Â Â Â Â Â Â Fruit Acid Peels offered in room during recuperation Â·Â Â Â Â Â Â Â Â Arrange appointments for hairdresserÂ and other beauty treatments . Safaris Options. Additional expenses not specified. Return air ticket to South Africa. Â Payment Terms: -------------------------------------- Payment for Accommodation Package to be made in full as per Pro Forma Invoice and paid to Surgeon and Safari via bank Transfer in order to confirm accommodation and services Any changes made after confirmation of your booking will be rescheduled if needed and / or adjusted and refunded accordingly Any bookings confirmed and not taken up will be subject to cancellation fees. Â Â -------------------------------------- Surgery - -------------------------------------- Please note that your decision to proceed with surgery will be made in consultation between yourself and your selected surgeon Surgeon and Safari is a facilitation company and offers you a full medical concierges service and are not qualified to make any medical comment nor offer medical advice or suggested treatment / procedures, these need to be discussed with your surgeon. Â Medical Evaluation: -------------------------------------- The fee quoted by Surgeon and Safari will be confirmed after further medical evaluation by the surgeon based on the medical history and requirements forwarded by yourself as requested and forwarded to the Surgeon After medical feedback from the surgeon we will be glad arrange a telephonic consultation with the surgeon prior to making a decision regards to your travel 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. Â Terms 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 or agreeing to any surgery. Â 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 Â Includes: -------------------------------------- The cost is all-inclusive whilst in South Africa for selected procedure: The surgeon, specialist anesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication whilst in hospital, pre and postoperative consultations in South Africa 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. Â Excludes: -------------------------------------- Any additional medical expenses that might have incurred for the safety of your health as a result of unforeseen complications Ã� please discuss with the surgeon. Insurance. Additional procedures. Â 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 pro forma invoice and will be deducted from the final account payable to the surgeon. Balance of the fee payable directly to the surgeon at your pre operative consultation Payment can be made in Cash or via valid Visa, Master and Amex Credit Card Any changes made to booked medical procedures which affect the costs initially quoted and / or paid will be reconciled, adjusted and payable or refunded with your final Surgeon Account If for any medical or unforeseen circumstances your surgery needs to be cancelled the costs paid will be reconciled, adjusted and refunded accordingly.
I have read the terms and conditions above:	Yes No
After sending this form we request that you also send us a close up photograph of the body area you are requesting the procedure for. This will assist further medical evaluation by the surgeon.
Enter Text Shown in Picture Below: