CONTACT AND ENQUIRIES


Please complete the form below to log an enquiry with us regarding Plastic and or cosmetic surgery.

Please note: this is an interim medical form
If you decide to proceed with your selected surgery, you will be required to complete the full Medical Questionnaire
which you can access by scrolling down this page and clicking the button 'Medical Questionnaire' or by clicking
button on the home page.


* Gender  Occupation 
* Name  * Email 
  Telephone 
Postal  Weight(kg) 
Address  Height(cm) 
  Date of birth 
* Country  Allergies?
       
How did you 
hear about 
First Appearance?  
Have you ever 
been to South 
Africa Before? 
Yes No
   
Any prescribed or  current medication  Past medical 
history 
          
    Surgical Procedure
required
   

** Please note COUNTRY and EMAIL are compulsory to submit the email



Please take note if you submit an enquiry and later wish to book surgery you will be required to fill out the full medical form. You can access this form by clicking the box below, titled Medical Questionnaire.

               


 

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