Download offline form - Fabulous Flying Birds

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.