Medical/Travel Form

Important Note: Please fill in the questionnaire as honestly, accurately and completely as possible. This is vital to aid the Surgeon to make a good judgment as to your suitability for general anaesthesia and the Surgery itself. This will also help us highlight the potential problems early so that you are able to get all the necessary documents and checks ready before you travel and reduce the chances of cancellation in cases where a client is deemed unsuitable for the surgery. Please be assured that any information or picture submitted to us will be only be viewed by your chosen Surgeon and Perfect Enhancement and will not passed on to any third party without your prior written consent. We will not use your contact details other than for the purposes of your treatment and holiday.

Important:
Occasionally, some emails from us end up in “Spam” folders. Kindly add our email info@perfectenhancement.com to your email address book to avoid our emails being marked as spam. If you are having trouble uploading your pictures, please send us the pictures via email and submit this form without the pictures.

Personal Information

First Name*
Last Name*
Gender *
Date of Birth (DD/MM/YYYY)*
Height (cm)
Weight (kg)
Address*
City*
State*
Country *
Occupation
Email*
Contact number (inc. country code)
Mobile Number*
Where did you hear about Perfect Enhancement? *

Surgery/Treatment

Please specify the surgery (or multiple surgery packages) that you are interested in *
Hospital/Surgeon Preferred *
Please describe why you would like such surgery and what is it that you are looking to improve or correct*

Medical History - Do you have any history of:

Heart Disease *
If yes, please specify*
Lung Disease (eg Asthma) *
If yes, please specify*
Blood/Bleeding Disorder or family history of bleeding disorder*
If yes, please specify*
Blood clots in Leg/Lung (DVT/Pulmonary Embolism) *
Depression or any Psychiatric Disorder *
If yes, please specify*
Diabetes *
If yes, is it well controlled?
High Blood Pressure *
If yes, is it well controlled?
Stroke *
Liver Disease *
If yes, please specify*
HIV/Aids *
Hepatitis *
If yes, please specify which type*
Epilepsy *
Cancers *
If yes, please specify*
Poor healing/keloids *
If you suffer or have had any illness not stated above, please specify here
Are you pregnant? *
If yes, please state far along are you*
Are you planning on having children or more children? *
Are you lactating? *

Family History

Any conditions that run in your family? *
If yes, please specify*
Any family history of heart attacks before the age of 60? *
Any family history of cancers? *
If yes, please specify*

Social History

Do you smoke? *
If yes, please specify how many a day and for how long*
If no, have you ever smoked? *
If yes, please specify when you stopped and how many you used to smokehere*
Do you drink alcohol? *
If yes, please specify how much and how regularlyhere*

Hospitalizations/Surgeries

Have you ever been hospitalized or had any surgeries in the past? *
If yes, please give detailshere*
Any previous problems with general anaesthesia? *
If yes, please state what kind of problemhere*
Have you ever been turned down for surgery by another Plastic Surgeon? *
If yes, please specify*

Medications

Please list the medications that you are currently on ( including oral contraceptive pills and hormone replacement therapy) and doses if possible
Are you on any health/herbal supplements? *
If yes, please specify*
Are you allergic to any medications that you know of? *
If yes, please specify*
Are you allergic to any food? *
If yes, please specify*

Pictures

Please upload clear close up pictures of the body part you wish to correct. If you are unsure of what kind of picture you need to take please refer to the surgery that you are considering on this website for details. Generally, front and side profile pictures are required. Maximum size per image is 2.5 MB. Only jpg, jpeg, gif, png or zip files allowed.
Picture 1
Picture 2
Picture 3
Picture 4
Picture 5
Picture 6
Picture 7
Picture 8

Travel

Please give a rough time period when you would like the procedure to be done
How many days are you intending to stay in Malaysia?*
Please select your accommodation *
How many people are traveling with you (please specify how many children and adults)?*

Terms and Conditions

Terms and ConditionsTerms and Conditions and important notices Perfect Enhancement Sdn Bhd This document sets out the contractual terms and conditions in relation to the services provided to you by Perfect Enhancement Sdn Bhd ("PESB" or "Us") By making any enquiry or booking with PESB, you ("You" or "I") agree to be bound by these terms and conditions. PESB strongly urges you to read the Disclaimer of Responsibility below and if you do not understand it, to seek your own independent legal advice. If any information provided by or on behalf of PESB is inconsistent with these terms and conditions, then you agree that these terms and conditions prevail to the extent of any inconsistency. PESB’s services Perfect Enhancement Sdn Bhd (PESB) is a Malaysian company that: 1. books hotels (herein referred to as the "Hotel Booking Services"); and 2. books elective plastic surgery (herein referred to as the "Elective Surgery Booking Services"). 3. undertake limited post-treatment monitoring (herein referred to as “Post-op Monitoring”) (without assuming principal responsibility for your treatment/surgery or its outcome) Incidental goods and services may be provided or booked on your behalf in connection with Hotel Booking Services, Elective Surgery Booking Services and Post-op Monitoring. For the purpose of these terms all elective surgery or procedures will be referred to as "Elective Surgery Procedures" and all bookings made for accommodation on your behalf at hotels are referred to as "Hotel Services". Important term: Other than making information from third parties available to you, introducing you to third party providers of goods and services, and booking, PESB is not itself providing you with any goods or services in the capacity of a principal, agent or sub-contractor. Important term: Third party principals (who are not agents of or sub-contractors to PESB) provide all goods and services to you (including travel, activities, meals, consultations, operations and procedures) that may have been booked by PESB on your behalf. Whilst PESB will do its best to exercise every reasonable care in the selection of the third parties to whom you are introduced and whom may provide the goods and services to you, PESB shall not be liable to you in any way whatsoever for any damage, loss or injuries which you may suffer arising from or in relation to the goods or services provided by these third parties to you. It is important to note, therefore that: (a) PESB's role is to merely introduce supplier of those goods and services to you and PESB does not make any expressed or implied representation or warranty that any goods or services supplied by third parties to you will be fit for your required purpose or supplied by them with reasonable care and skill; and (b) the goods and services to be provided by third parties are subject to the terms and conditions and limitations of liability as may be separately imposed by the third parties (namely, the hospitals, clinics, hotels and other providers of goods and services to you) (some of which limit or exclude liability in respect of death, personal injury, delay and loss or damage to baggage). Upon arrival in Malaysia (if you are an International Client) At the time of payment for your accommodation, PESB will book all hospital, clinic appointments (as the case may be) and hotel accommodation and transfers. During your stay in Malaysia, you will be assisted by a representative from PESB who will provide the pick up and transfer at the airport at a prearranged time. On the day following your arrival, you will have an appointment with the nominated Surgeon for a pre-operative consultation (Surgeon Consultation). Within 48 hours of the Surgeon Consultation and provided that the Surgeon and you agree to proceed with the Elective Surgery Procedures, you will be admitted to the Hospital for the purpose of undergoing the Elective Surgery Procedure. Following the Elective Surgery Procedure, you will remain in the Hospital for an observation period and post operative consultations as required by the Surgeon. At an appropriate time (as determined by the Surgeon), you will be discharged from the Hospital and return to your hotel/accommodation. The Surgeon will recommend a period of time that you should remain in Malaysia for recuperation. PESB’s Doctor (herein referred to as “Doctor”) will visit you for the first three days after discharge from hospital (which constitutes three visits only to be made within the first three days post-discharge as mentioned) and phone follow-ups will be made daily by PESB’s representative (Doctor or otherwise) as would be deemed reasonable or necessary by PESB depending on your condition and needs. For details of the role of PESB’s Doctor, please refer below. PESB will make its best efforts to ensure that its representative is contactable 24 hours a day during the time you are in Malaysia. If you would like to add, change or cancel any bookings or treatments, please give at least 48 hours notice to the representative. This process described above may vary from patient to patient. PESB’s Doctor(s) Neither PESB’s Visiting Medical Consultant nor any Doctors employed by PESB are Plastic Surgeons or Specialists in any treatment offered in PESB’s packages (hence these treatments are not performed by PESB’s Doctors but rather by suitably qualified Third Party Surgeons chosen by PESB). Therefore, you accept that any opinion, advice or recommendations made by PESB’s Doctors, expressed or implied, must only be taken within the context of that of a mere General Practitioner and hence may not be entirely accurate or complete given the variable nature surgical treatments, techniques, opinions and recovery protocols depending on the Surgeon performing the surgery or procedure. It is therefore essential that issues concerning the treatments or surgeries offered in PESB’s packages e.g. risks, possible complications, surgical procedures, expected recovery and results etc. must be brought up and discussed by yourself with your nominated Surgeon either in physical Consultation or other means which can be facilitated by PESB. PESB’s Doctor’s role involves only examination of the surgical wound and, within the limitation of the equipment available to the Doctor, your overall medical well-being. The Doctor will not in anyway intervene either by way of any procedure, treatment or prescribing of medication. The Doctor will document and report to the treating Surgeon of your current condition after every visit. PESB’s treatment packages will only include three Doctor consultations/visits after you are discharged from hospital and these consultations must take place within the first three days after hospital discharge. Any further consultations, within the mentioned three days or otherwise, a fee of RM 100 will be made payable for each consultation/visit you request. The payment must be made in cash to the visiting Doctor at the time of the visit. An official receipt will be issued upon payment or at a later time by PESB’s representative. These consultations/visits will generally be done after working hours (usually after 5pm) and you will be expected to remain in your chosen accommodation for the period agreed between yourself and PESB’s Doctor for these visits. Should there be any medical problems or potential problems, PESB’s Doctor will advise you, with the consent of the treating Surgeon, to urgently seek treatment in Hospital (if possible the Hospital where you had your surgery or treatment). PESB can arrange transportation for this purpose which may result in extra cost to you. Important term: You accept that PESB does not accept any liability of whatever nature in the case of any complications or death as a result of the treatment or surgery you underwent unless it can be proven beyond reasonable doubt that negligence in the part of PESB or PESB’s Doctor(s) contributed directly to the mentioned complications or death. PESB strongly recommends that you seek professional medicolegal advice before you consider any legal proceedings. Website & other Marketing Material: PESB make no warranties that the information contained within the company website or any other publication is in every respect accurate or complete, and are not responsible for any errors or omissions or for the results obtained from the use of such. Users of this information are encouraged to confirm the information contained herein with other sources. In case of doubt also please check with your own doctor. The information is not intended to replace medical advice offered by surgeons or other health care professionals. Our web site links to other web sites but is not responsible for any information found on these or any other associated or linked web sites. The links are not an endorsement of the information on other web sites. Important term: The information on PESB’s website, and all other information provided by PESB is a partial summary of plastic, cosmetic and reconstructive surgery in general. You acknowledge and accept that such information does not replace talking with a surgeon. Publicity You must give PESB ample time to react and address issues which have led you to seek or consider seeking legal action against PESB. Before seeking publicity, you have to consider that in case PESB are not to be held responsible, all damages suffered by PESB as a result of negative publicity will be claimed against you. This is PESB’s exclusive right. We therefore recommend you seek advice on this matter, and to discuss your case with one of many private and public medical organisations that can determine how meritorious your case is. If it is in PESB’s opinion that your claim is not appropriate, PESB will inform you accordingly with the reasoning behind our decision. If you, despite our reasoning, decide to proceed with legal action against us, this is a right we cannot and will never deny. The difference between seeking legal action and seeking publicity is sometimes a fine balance. If the outcome of the legal action proves you wrong and you have sought publicipaity to strengthen your case, it is our right to take legal action against you if the publicity results in damages/loss of business to PESB. Surgeon Consultation The Surgeon Consultation serves a number of purposes. These include the following. 1 The Surgeon Consultation will help the Surgeon determine the appropriateness (from a medical perspective) of each Elective Surgery Procedure you wish to undergo. 2 The Surgeon will take the opportunity to explain the surgery and the procedure. The Surgeon will also inform you of any form or consent which the hospital may require from you or to be signed by you. 3 To give you the opportunity to meet the Surgeon and ask any questions you may have. 4 To give you the opportunity to decide and confirm whether to go through with the Elective Surgery Procedure. 5 In addition, the Surgeon will determine if any additional procedures are required that will add to the cost as set out in the Pre-Consultation Price Estimate. Both you and the Surgeon are under no obligation to proceed with an Elective Surgery Procedure at any time. Price for Elective Surgery Procedures The price for Elective Surgery Procedures is determined in two stages. 1. Stage 1: Based on the information provided by you to PESB, PESB will make enquiries with third parties for the purpose of giving you an estimate of the price for Hotel Services and Elective Surgery Procedures. This estimate is herein referred to as the "Pre-Consultation Price Estimate" (the price for Hotel Services and Elective Surgery Procedures will be separately itemised). 2. Stage 2: Following your arrival in Malaysia, you will be required to attend the Surgeon Consultation. Following the Surgeon Consultation, the final price for Elective Surgery Procedures will be determined (the "Final Price Amount"). When the Final Price Amount is decided and agreed by you, you will pay the amount directly to the hospital in accordance with the terms of payment of the hospital - before surgery. Items included in the Pre-Consultation Price Estimate The Pre-Consultation Price Estimate will include each of the services specified below: (a) Hotel Services: The estimated price for Hotel Services, which may include (subject to your required package) the following: (1) Accommodation at a specified hotel; (2) Transfer from the Kuala Lumpur airport to your hotel and return to Kuala Lumpur airport; (3) Transfers from your hotel to the hospital and return to the hotel for the initial consultation, the elective procedure and at least one further visit to the hospital for post operative attention; and (4) Meals (if you elect for meals to be included in your package). (b) Elective Surgery Service: The estimated price of each Elective Surgery Procedure and the related On Cost (as defined below) for that particular procedure. Important note: You acknowledge and accept that the estimated price of each Elective Surgery Procedure is only an estimate and is subject to changes or variations after the Surgeon Consultation. Unless otherwise specified in your Pre-Consultation Price Estimate, the "On Costs" for each Elective Surgery Procedure includes: * One Surgeon Consultation; * Surgeons’s fee * Anaesthesiologist fee(if required); * Post operative accommodation at the private clinic/hospital for the specified period of time for the required procedure; * all theatre charges for carrying out the required procedure; * general medication required immediately following operation, * one week’s prescribed medication post discharge from hospital * post-operative consultation prior to your departure from Malaysia. It is not possible to determine the exact price of Elective Surgery Procedures without first having the Surgeon Consultation (as discussed above). Items excluded in the Pre-Consultation Price Estimate and the Final Price Quote The following goods and services are excluded from the Pre-Consultation Price Estimate and the Final Price Amount. (a) Any additional medical expenses that might be incurred following any Elective Surgery Procedure as a result of unforeseen complications or as may be included in the Final Price Amount. (b) Travel insurance and / or any medical insurance (see discussion below). (c) Any procedure for which an estimate is not given in respect of in Pre-Consultation Price Estimate and the Final Price Quote. (d) Tours or outings. (e) Any time spent at a hotel in excess of the departure date specified in the Pre-Consultation Price Estimate and the Final Price Amount. (f) Additional expenses not specified in the Pre-Consultation Price Estimate and the Final Price Amount. (g) Meals (unless they are specified in the Pre-Consultation Price Estimate and the Final Price Amount as being included in the price). (h) Air tickets (or other transport) to/from Malaysia. (i) Airport or departure taxes, road tolls, laundry, beverages, gratuities or tips. (j) Additional costs incurred by weather or failure of transport services or other circumstances beyond the control of PESB. Validity period of Pre-Consultation Price Estimate The Pre-Consultation Price Estimate is valid for 21 days from the date on which it is given to you, or an earlier date if advised by PESB. Can the final price vary from the price in the Pre-Consultation Price Estimate and the Final Price Quote? Yes. For example, 1. Pre-Consultation Price Estimates are expressed in a specified currency and reflect anticipated exchange rates unless otherwise indicated. Prices are subject to review (and change) as PESB, the relevant hospital or hotel may advise. 2. As discussed above, the Elective Surgery Procedures may vary following the Surgeon Consultation. 3. All credit card payments are subject to exchange rate fluctuations, determined by your issuing bank. Terms of payment If you wish to use the Hotel Booking Service and Elective Surgery Booking Service, the following procedure applies. 1. Initiation/Commitment fee: After the initial enquiry, you will be required to fill in the medical/travel form and submit pictures of the body parts concerned in the treatment. Upon receipt of this form, PESB will invoice you via email for an Initiation/commitment fee of RM 150 (a link in the email invoice will lead you to a secure online payment portal – iPay88) payable by credit card (Visa or Mastercard). This fee will be refundable if the Surgeon decides not to take up your case. 2. Confirmation of Pre-Consultation Price Estimate: PESB will confirm that the Pre-Consultation Price Estimate is correct, that prices for Hotel Services and Elective Surgery Procedures have not varied and that your requested dates remain available. 3. Pay for Hotel Services and any flights: After PESB gives you confirmation of the Pre-Consultation Price Estimate and confirms availability of requested dates, then you can book the Hotel Services and Elective Surgery Procedures as set out in the confirmed Pre-Consultation Price Estimate by paying for a sum as may be specified by PESB [the hotel accommodation and any flights] (“the Deposit”) (see the "Important Term" below regarding the non-refundable conditions attaching to the Deposit). All invoicing will be done via email and a link will be provided in these emails that will lead you to a secure online payment portal (ipay88) where you can pay using credit card (Mastercard or Visa). 4. Pay for Elective Surgery Services: After the consultation, when costs have been confirmed by the surgeon and agreed by you, you will pay for the surgery procedures direct to the hospital. You shall pay the hospital directly for your Elective Surgery Procedure, your stay at the hospital and all another costs in relation thereto in accordance with the terms of payment of the hospital Important term: You acknowledge and agree that the Deposit is non-refundable to you in any circumstances. Cancellation of treatment/surgery If, following the Surgeon Consultation, the Surgeon or yourself elects not to proceed with the Elective Surgery Procedure, none of that amount paid for the Hotel Services will be refundable to you (the Deposit). Important term: When booking the holiday and procedure, it is important that you understand that the price and dates specified for consultation, procedures and recovery time are set out in the Pre-Consultation Price Estimate. You acknowledge and agree that PESB is not responsible for organising any travel to or from Malaysia. Accordingly, you are responsible for ensuring that you are able to arrive and depart on the dates specified in the Pre-Consultation Price Estimate. Varying of Accommodation/Hotel booking Following the payment of your accommodation, you may amend your dates of travel, subject to any surcharge or fee imposed by the hotel in respect thereof. This must be done a minimum of 7 (seven) days prior to check-in to the hotel/accommodation. Failing this, the payment will be forfeited. Passport or visa for Malaysia PESB is not a travel agent and does not provide advice in relation to visa or passport requirements for Malaysia. It is your responsibility to make sure all required travel documents when entering Malaysia are valid and correct. Travel and medical insurance PESB does not include any insurance in the cost of the Hotel Services or Elective Surgery Procedures. Accordingly, PESB strongly recommends that you take out travel insurance, so that you will be comprehensively insured for your travel to and in Malaysia. Subject to your requirements, PESB recommends that you take out travel insurance that covers you against cancellation fees and loss of deposits, emergency medical, overseas medical and hospital expenses, thief, luggage delay, travel delay, personal liability and car rental excess Certain travel insurance may not cover you for costs incurred as a result of elective surgery or medical malpractice in connection with elective surgery. PESB recommends that you consider obtaining specialist insurance for this purpose. PESB strongly recommends that you disclose all relevant matters to your insurer (including the fact that you may be undertaking elective surgery as part of your travel). Important term: You acknowledge that PESB has not offered you any insurance or advice in relation to a particular insurance product. You have reviewed the terms of your insurance policy (if any) and are satisfied that it provides you with the level of insurance you consider that you require. Limitation of Responsibility and Liability PESB provides the Hotel Booking Service, Elective Surgery Booking Service and limited Post-op Monitoring only. Other than making information from third parties available to you, introducing you to third party providers of goods and services, organising tickets and facilitating payment of goods and services by you to third parties, PESB is not itself providing you with any goods or services in the capacity of a principal. Third party principals (not sub-contractors to PESB) provide all goods and services to you (including tours, travel, activities, meals, consultations, operations and procedures). PESB will use its best efforts to exercises every reasonable care in the selection of third parties to whom you are introduced and who may provide goods and services to you in connection with a tour. It is important to note, therefore that: (a) PESB’s role is to merely introduce you to the supplier of those goods and services and PESB does not make any express or implied representation or warranty that any goods or services supplied by third parties to you will be fit for your required purpose or supplied by them with reasonable care and skill; and (b) the goods and services to be provided by third parties are subject to the terms and conditions and limitations of liability as may be separately imposed by tour operators, airlines, hospitals, clinics, dentists, hotels and other providers of goods and services to you (some of which limit or exclude liability in respect of death, personal injury, delay and loss or damage to baggage). PESB does not accept any liability of whatever nature for the acts, omissions or default, whether negligent or otherwise, of tour operators, airlines, hospitals, doctors, clinics, dentists, hotels and other providers of third party goods and services to you directly or indirectly in connection with any goods and services booked by PESB on your behalf. Without limiting the provisions of this clause, you agree to be bound by the terms of any contract between a third party provider of goods and services and yourself (which may be evidenced in writing by the issue of a ticket, voucher, coupon confirmation or the like). PESB does not accept any liability in contract or in tort for any injury, damage, loss, delay, additional expenses or inconvenience caused directly or indirectly by force majeure or other events which are beyond our control, or which are not preventable on our part. Governing Law Any service or contract provided by PESB in accordance with the terms hereof is deemed to be made in Malaysia and are subject to the Laws of Malaysia. Any disputes must and will be dealt with within Malaysia and you agree to submit to the jurisdiction of the Courts of Malaysia. Any provision of, or the application of any provision of, these terms and conditions which is void, illegal or unenforceable in any jurisdiction does not affect the validity, legality or enforceability of that provision in any other jurisdiction or of the remaining provisions in that or any other jurisdiction.*
Your Full Name*
I confirm that I have read, understood and accepted the terms and conditions and that the information above is to the best of my knowledge true.