1. Your Contact Information

*Reference#:

*Title:

*First Name:

*Last Name:

*E-mail Address:

Street Address:

City:

State:

Zip/Postal Code:

*Country:

Telephone:

Your age:

Have you been to Thailand before?

Have you had cosmetic surgery before?

2. Surgical Procedures

Select procedure, holding down the Control key for multiple selections. We list the more popular procedures. If the procedure you want is not listed here, please use the comments section at the end of this form to inquire about it.

Cosmetic Surgery:

Are you able to e-mail digital photographs of yourself showing area(s) for treatment?

Your preferred on-line consultation:

Dental Surgery:

Other Surgery:

Do you have any pre-existing medical condition that may affect your surgery?

3. Non-Surgical Cosmetic Procedures

Select procedure, holding down the Control key for multiple selections. We list the more popular procedures. If the procedure you want is not listed here, please use the comments section at the end of this form to inquire about it.

None Botox or Dysport injection Chemical peel Decollete toning Dermabrasion Hand plumping Laser hair removal Laser skin resurfacing Laser treatment of leg veins Microdermabrasion Soft tissue filler Spider veins treatment Tattoo removal Other (specify in the comments section below)

4. Wellness and Spa Treatments

Select procedure, holding down the Control key for multiple selections. We list popular procedures. If the procedure you want is not listed here, please use the comments section at the end of this form to inquire about it.

None Acupuncture treatments Anti-aging introduction and/or treatment Blood workup Day spa Healthy woman checkup Executive health checkup Meditation Natural therapies Retreat Traditional Thai massage Other (specify in the comments section below)

5. Your Travel Arrangements

Do you intend to travel once your doctor discharges you?

How many persons will accompany you?

Arrival date in Bangkok:

Time of arrival:

Departure date from Bangkok:

Time of departure:

6. Terms and Conditions

Please read our terms and conditions below, and indicate where required that you agree with them.

Cosmetic Surgery Travel LLC (CST) is responsible for arranging your trip, by arranging and booking your medical and surgical services, accommodation, tours and other events as requested. CST is not itself a transport, accommodation, tour, event or medical service or product provider. Third parties independent of CST provide those goods and services to you. It is therefore important for you to obtain and read the service provider’s terms and conditions applicable to the goods or services they provide and make sure that you are aware of any exclusions or limitations of liability imposed by the service provider. Some of these may limit or exclude liability for death, personal injury, delay and property loss or damage. To the extent permitted by law, CST excludes all liability for any loss or damage whatsoever and howsoever arising (including but not limited to physical and psychological injury and loss or damage to property of whatever nature) that may arise in any way in connection with the offer or supply of goods or services by or through CST or any third party service provider or in connection with the supply of such goods or services. You release CST and its officers and employees from all such liability and indemnify each of them severally against any such claims that may be made by or through you. Except for any condition or warranty implied by law which cannot be excluded, CST makes no statement, representation or warranty that any goods or services supplied by third parties will be fit for your required purpose or supplied by them with reasonable care and skill or as to the safety, conditions, standards or other issues that may exist at any destination or service provider. The liability of CST for a breach of the condition or warranty will be limited as determined by CST in its absolute discretion to (a) in the case of goods, any one or more of the following (i) the replacement of the goods or the supply of the equivalent goods or (ii) the payment of the cost of replacing the goods or of acquiring equivalent goods and (b) in the case of services (i) supplying the service again or (ii) the payment of the cost of having the services supplied again. CST also does not accept any liability whatsoever for any injury, damage loss, delay, additional expense or inconvenience caused directly or indirectly by any events which are beyond its control including but not limited to war, civil disturbance, terrorist attack, fire, flood, acts of God, acts of Government or of any other authorities, accident to or failure of machinery or equipment or industrial action. You acknowledge that any medical advice, procedure or other service that you ask CST to book on your behalf carries risk. Accordingly, without limiting the more general provisions of this disclaimer, you specifically represent and warrant to CST that (a) you have obtained or been advised by CST to obtain independent medical advice from a appropriately qualified medical practitioner in relation to any medical services that you have asked CST to book on your behalf (b) CST has not given you any advice or expressed any opinion that a reasonable person would consider as being an advice or opinion of a medical nature (including with respect to any risks, side effects or otherwise) (c) even though CST may have provided information regarding the availability of medical services or booked medical procedures, products or other services on your behalf, CST takes no responsibility whatsoever and excludes all liability for the actual medical services provided and (d) You accept and are solely responsible for these risks and will not hold CST or its officers or employees responsible in any way you use those services solely at your own risk. CST strongly recommends that you take out travel insurance and disclose all relevant matters to your insurer (including the fact that you may be undertaking elective surgery as part of your travel).

Please use this space to further explain your selections, as needed.

Thank you for your interest in Cosmetic Surgery Travel. We will respond to your request within 48 - 72 hours.