Applying for treatment or information:

Please give your particulars, then give a detailed description of your physical health, what kind of treatment you require. You may also include questions. (filling all parts marked * are obligatory)

If applying: indicate what you are interested in. We arrange details via phone or in e-mail, where we give answers to occurring questions.

We handle your particulars confidentially, we do not give them to anybody else, we do not send you unwanted letters.

Personal

Title Mr Mrs Miss Ms
First Name*
Surname*
Year of birth
E-mail*
Contact telephone number*
Other telephone number

Address

Country
Address
City
Postcode

Interested in*

Dentistry SPA & Pampering
Cosmetic Surgery Health Check & General Surgery
Laser Eye Surgery Other

if other

Planned travelling date:

as soon as possible within 3 month in a half year I don't know

How did you hear about us*:

Recommended by a friend Search engine (Google, Yahoo...) Gumtree or other web classifieds Auction site (eBay, Qxl..) Newspaper Magazine Leaflet Other

if other

Your expected treatment description, or any question:

You can contact us in our London office:

• | Dental Surgery|
• | Laser Eye Surgery|
• | Cosmetic Surgery|
• | SPA & pampering|

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