General Enquiry Form

Thank you for visiting the Surgery and Holiday web site.
We will reply with relevant details and cost estimates as soon as possible.

Name First Name Mail Postal Address City Country Po box Phone number Fax Have you been in Tunisia before? Yes   No How did you hear about Surgery and Holiday

SURGICAL PROCEDURE
Specify procedure (For multiple selections please hold down the Control key and make your selections with your mouse.)	None Breast Augmentation Breast Lift Surgery Breast Reduction Liposuction Abdominoplasty Rhinoplasty Blepharoplasty Brow Lift Cheek Augmentation Chin Augmentation Otoplasty Lip Augmentation Hair Transplant
Would you be able to e-mail a digital photograph of yourself	Yes   No
Preferred online consultation	Phone   Mail

NON-SURGICAL PROCEDURES
Specify procedure (For multiple selections please hold down the Control key and make your selections with your mouse.)	None Botox Perlane Restylane

RECUPERATION ACCOMODATION PACKAGE
Are you interested in our Recuperation Accommodation package ?	Yes   No
Specify type of package ?	Hotel Type of room Accommodation mode Single Double Twin BB Half Board Full board Own arrangements

HOLIDAY OPTIONS
Specify excursion choice (For multiple selections please hold down the Control key and make your selections with your mouse.)	None Holiday Countr y Holiday Day Holiday

TRAVEL ARRANGEMENTS
Would you like a cost estimate on your flights ?	Yes   No
Specify CLASS of travel requirement.	Economy Business First Class
Specify intended travel dates	Start Date Select Month January February March April May June July August September October November December Select Year 2008 2009 End Date Select Month January February March April May June July August September October November December Select Year 2008 2009

IT IS IMPORTANT TO READ 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 Euro 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. Excursions and tours Options. Additional expenses not specified. Meals ( Depending on the type accommodation choice ). Return air ticket to Tunisia. Payment Terms: -------------------------------------- Non-Refundable Deposit required securing your booking. Deposit to be invoiced and paid to Surgery and Holiday 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. Surgery & Holiday 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 Tunisia, under Tunisian Law. Any medical or surgical advice provided through the Surgery & Holiday 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 Tunisia 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 Ð 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,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 Surgery & Holiday 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 Payment can be made via valid Credit Card orTravellers Cheque.
I have read the terms and conditions above
What are the factors that are most important for you on your surgery holiday ? (For multiple selections please hold down the Control key and make your selections with your mouse.)	Price Quality - skilled surgeons and hospitals Follow up support and service A relaxing holiday Privacy
Please do not hesitate to ask for any further questions you might have concerning the services offered on our web site or any additional procedures you might require.
Please be assured that all electronic data received is treated with the strictest confidentiality.