Booking Form:

Please fill in the booking form to secure your aesthetic surgery holiday in Malaysia.

All bookings must be accompanied with payment of the non-refundable service charge which can be paid by credit card or direct transfer, money order or bank cheque. Payment for all surgery expenses is payable directly to the hospital after your consultation with your surgeon, once you feel confident and are happy to proceed.

Contact details (a booking form must be filled in by each person having surgery)

*First Name:
*Last Name:
*Street Address:
*Suburb:
*Postcode:
*Country:
*Email:
Telephone:
Mobile:
*Date of Birth:
 

Next of Kin
*Name:
*Email:
*Telephone:
Relationship:
Aesthetic Procedures
Which Procedure would you like to book:

 
If your procedure is not listed above please specify:
Surgeon:
Preferred Hospital:

What are your personal goals for having surgery?

 
Accomodation and Flight Information
*Which accommodation package would you like to book:
*Number of Travelling Adults:
*Names of Other Persons Travelling:
*Arrival Date:
*Departure Date:
*Number of Days:
*Time of Arrival:
*Airline and Flight Number:
*Time of Departure:
*Airline and Flight Number:
Newsletter & Special Offers
Declaration
 

*       I have read, understood and accept the Terms & Conditions  from Aesthetic Escapes
 

* Required
Please read the following Disclaimer carefully and forward a signed copy to Aesthetic Escapes.
 
e-newsletter
name: email: