Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Take a break and feel fabulous ENQUIRY FORM Please complete the following questions to receive information regarding Surgery and Treatment prices, Accommodation and Service packages, Payment and Bookings. PERSONAL INFORMATION First Name __________ Last Name __________ Email Address __________ Phone Number (with country & area codes) __________ Mobile Number (with country & area codes) __________ Date of Birth __________ SURGERY/ TREATMENT DETAILS Cosmetic Dental __________ Eyelid Surgery Nose Reshaping Face Lift Forehead Lift Neck Lift Chin & Ear Improvement Lip Enhancement & Reduction Breast Enlargement Breast Reduction Liposuction Abdominoplasty Scar Correction Removal of Skin Lesions Laser Resurfacing Treatment for Wrinkles & Frown Lines __________ Scaling & Polishing Filling Normal Extraction Surgical Removal of Impacted Upper Wisdom Surgical removal of Impacted Lower Wisdom Root Canal Treatment (RCT) – One Root Root Canal Treatment (RCT) – Two Roots Root Canal Treatment (RCT) – Three Roots ++ Composite Veneer Ceramic Veneer Emax/ Zirconia Ceramic Crown Porcelain Fused Metal (PFM) Crown Bridge (PBM) Bridge (Zirconia) Denture Implant with Crown Orthodontics – Invisalign Orthodontics – High-Technology Friction Free Bracket (Stainless Steel) Take a break and feel fabulous Orthodontics – High-Technology Friction Free Bracket (Ceramic) Orthodontics – Mini Screw Teeth Whitening Homecare Maintenance Kit OPG, Lateral Ceph, PA Skull PVS Impression Study Model CBCT Upper & Lower Jaw Laser Gingivectomy Optical __________ General Eye Care & Visual Evaluation or Screening Glaucoma Screening & Follow Up Paediatric Eye Care Diabetic Eye Disease Evaluation Corneal Disease Ocular Surface Diseases-Pterygium Excision Dry Eye Management Age-Related Macular Degeneration (AMD) Argon Laser & YAG Laser Treatment Lid Surgery, Wart, Stye & Mole Removal No-Blade Cataract No-Blade LASIK iContact Lens or Implantable Contact Lens Reading Vision Correction (KAMRA) Other __________ TRAVEL DATE We recommend that you plan for a 7 or 14 day medical holiday. Please indicate the dates or month you wish to travel__________ (Calendar) MEDICAL INFORMATION Do you have any medical conditions? Please describe __________ (Yes/ No) __________ Are you taking any medication? Please list __________ (Yes/ No) __________ *Do you smoke? __________ (No/ Occasionally/ Regularly/ Heavily) Please give details of any other surgery or treatments__________ Other important medical information __________ *SMOKING may delay recovery and healing and increase the risk of infection. It is strongly recommended that you stop smoking for one (1) month before and one (1) month after surgery. *ASPIRIN may cause the risk of excessive bleeding. Any type of aspirin, medicines containing aspirin or anti-inflammatory medicines may not be taken 10 days before surgery. PRIVACY All personal and medical information received from potential clients shall remain absolutely confidential between Fabulous Flying Birds and the Doctor, Surgeon or Specialist involved in the relevant treatments or procedures.