Ophthalmic Surgery Medical Form

Thank you for visiting the Surgery and Holiday web site.
Surgery and Holiday will forward your medical details to your selected surgeon who will reply with his basic clinical evaluation and any relevant details as soon as possible.

Please Note: For this enquiry to reach us you must provide a valid email address.

Name
First Name
Date of Birth
Postal Address
Country
Phone number
Fax
Mail
Occupation

Hyperopia (Far Sighted)	Yes No
Myopia (Short Sightedness)	Yes No
Astigmatism	Yes No
Keratoconus (Irregular astigmatism)	Yes No
Do you need reading glasses ?	Yes No
Blindness	Yes No
Any other eye disease ? Please specify
Contact Lenses	Yes No
Type - Hard or Soft
Strength Right Eye
Strength Left Eye
Previous Eye Surgery ? Please specify below	Yes No
Procedure
Current Eye Medication
Recent Optometrist Report
Refraction Right Eye
Refraction Left Eye
Stable refraction > 2 years

General History
Allergies
Hypertension
Diabetes
Malignancies
Current Non Ophthalmic Medication
Have you had your Cornea tested for suitability to Excimer laser surgery	Yes No
If so, please give summary of results
Please state the recommended procedure if applicable

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

Please be assured that all electronic data received is treated with the strictest confidentiality.

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