About your Surgery Program!
about your surgery plan and interested procedures
When is your surgery plan? (Please specify)
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Month
-
Day
Year
Date
What procedures / Promotion are you interested in? Please list it down here!
Accommodation Plan Preferences
Stay at Med Harbour's Accommodation! (No Extra Cost): I focus on post-op care treatment and daily wound care by Med Harbour. I prefer to stay with Med Harbour and go with the plan recommended by Med Harbour.
I go with Med Harbour's recommendation (No Extra Cost) : First stay at Med Harbour (first halft) and once I'm better. The timing and stay will be according to the plan.
I am serious about Hotel room. As soon as I'm discharged from recovery room I want to be transferred to Hotel immediately. I can pay extra charges for the hotel fee.
I DON'T WANT ANY ACCOMMODATION : as I have booked my own hotel. I just want the price of the surgery only.
I'm still not sure about the accommodation yet.
Other
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Let's we know more about you!
Name
First Name
Last Name
Age
Date of Birth
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Month
-
Day
Year
Date
Gender
Male
Female
Email (important as the quotes and surgeon's letter will be sent via email address)
example@example.com
Phone Number
Race/Ethnicity
Emergency Contact Name
First Name
Last Name
Medical Conditions/Questions
Current Medication / Allergies?
Do you drink alcohol?
Never
Occasionally
Daily
Are you smoking?
Never
Occasionally
Daily
Are you taking any illicit drugs?
Never
Occasionally
Daily
Have you undergo any surgery before? If yes, please provide the surgery procedure's name, date, and reason.
Do you have a family history of any of the following? Please check the below, if none, then leave it blank.
Hypertension
Stroke
Heart Disease
Diabetes
Cancer
Anemia
Other
NOTES / Anything you want to let us know.
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