About your Surgery Program!
about your surgery plan and interested procedures
When is your surgery plan? (Please specify)
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Day
-
Month
Year
Date
What procedures / Promotion are you interested in? Please list it down here!
Accommodation Plan Preferences
Surgery only, ( I have my accommodation)
Surgery and Recommended Post Op Care 7 days at Med Harbour + Free Hotel 3 Nights!
Surgery and Post Op Care 7 days + Free Hotel 3 Nights + Extended Stay for 4 days at 400 AUD
Surgery and 7 Post Op Care Plan + Free Hotel 3 Nights + Extended Stay for 10 Days at 900 AUD
I'm still not sure about the accommodation yet.
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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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