PCS on behalf of Keina Beauty - Dr Risma
This form is to help Dr Risma help deliver a smooth consultation for your blepharoplasty surgery.
Name
*
First Name
Last Name
Phone number including area code
*
Australia is +61
Email
*
example@example.com
Resident country
*
Street Address
Street Address Line 2
Time difference to Bali below if known
State / Province
Do you want upper or lower bleph, or possibly both?
*
Do you prefer local or general anaesthetic?
*
What date and time do you arrive in Bali?
What date and time do you leave Bali?
Have you had bleph or any other eye surgery before?
Do you understand the costs, $1500 single bleph, $2200 upper & lower? (local anaesthetic only)
What is your ideal surgery date?
*
What is your DOB
What hotel are you staying at and what dates?
The packages includes virtual support, tips, information and advice, please tick below which ones you would like from PCS:
Travel tips, what to pack, things to expect arriving in Bali etc.
Mindset tips, handling nerves and anxiety, keeping a realistic attitude
Health tips, how to prepare for surgery
Financial tips, preparing money for Bali and surgery etc
Practical tips, preparing as much as possible in all areas
Environmental tips, hotels, rooms prep etc.
Caring for yourself during the initial post surgery phase, such as IV Infusions, jamu drinks and massages etc
Ongoing tips, once you're back home, how to continue supporting your recovery
Is this your first time in Bali?
Are you coming to Bali alone?
Is this your first cosmetic surgery? If not, please let us know what procedures you've had, when and where below please
Please may we share your photos on social media to inspire others?
Yes this is ok and has no restrictions
Ok but don't use my name
ok but block out my main identity
No, I prefer to be completely private
Do you have any illnesses or diseases that you know of, if so please list below
Are you on any medication? if so please list below
Where did you hear about Dr Risma?
Is there anything else you would like to share with us?
Keina & PCS extra info, please can you read them, then tick to acknowledge:
*
The consultation cost $25, if you proceed with the surgery, this comes off the total bill
If the surgery date is confirmed, a 20% non-refundable deposit, the final 80% is paid the day of surgery.
Packages include the concierge wrap around service, supporting you before, during and after.
Includes transport within Sanur area only, extra charges apply outside Sanur.
You must stop smoking 2 weeks before surgery, including vaping. And alcohol also, as this can impair the healing as well as your health.
You will have 2 following appointment after surgery, 1st check up and 2nd for stitch removal.
A member of PCS team will visit you at your accommodation for 2 days post surgery to assess your condition and report back to Dr Risma.
Please note some additional fees may be added from bank charges or PayPal, these are passed on to the customer.
Please can you upload a recent photos showing front, sides, without eyewear for Dr Risma.
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