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Enquiry Form
Medical Form
Photograph Making
Enquiry Form
Medical Form
Photograph Making
Tel.: +34 945 467 393
Fax: +34 971 254 686
CALL FREE NOW
All information that you provide is treated under the rules and regulations of the Spanish data protection law. Your privacy will be respected at all times.
* Please, fill in the mandatory fields.
Medical Questions.
* Surname:
* First Names:
* Email:
Home Telephone:
* Contact Telephone:
* Postal Address: (House/Flat No and Street)
* Postal Address: (Town)
* Postcode / Zip:
* County/province:
* Postal Address: (Country)
Gender:
male
female
Have you visited Mallorca before?
no
yes
How did you learn about Mallorca medical Group?
Date of Birth:
1
2
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9
10
11
12
1
2
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Year:
Occupation:
Name & Address
of GP/house doctor:
Medical History.
In you own interest, it is essential you inform us accurately about your health.
Procedure/s of your choice
breast
body contour
genitalia
face
hand/reconstructive
botox
fillers
mesolifting
peelings
happyLift threads
other treatments
Please Specify: (If Appropriate)
Do you suffer from or have a History of:
Heart Disease:
no
yes
High Blood Pressure:
no
yes
Epilepsy:
no
yes
Any Other Serious Illness:
no
yes
If Yes, Please Give Details:
Is your Family Prone to certain Diseases:
no
yes
If Yes, Please Give Details:
Have you had any mamography:
no
yes
If Yes, Please Give Details (when and Result):
Please Indicate & Give Details of:
Smoker:
no
yes (If yes, How many Cigarettes Per Day?)
Pregnant/Breast Feeding:
no
yes
History of Fever Blisters:
no
yes
Cortisone:
no
yes
Medicine for High Blood Pressure:
no
yes
Antibiotics:
no
yes
Roaccutane:
no
yes
Anticoagulants:
no
yes
Aspirine or Salicylic acid containing medication:
no
yes
Details of Other Medication:
Do you have Any Allergies eg: Penicillin:
no
yes
If Yes, What:
How many Pregnancies have you had:
If so, how much weight you took in the heaviest one:
Have you had any Cesarean Sections:
no
yes
If Yes, Please Specify Procedure and Approximate Dates:
Have you had Cosmetic Surgery before:
no
yes
If Yes, Please Specify Procedure and Approximate Dates:
Please Specify Any Other Information:
Height:
Weight:
Do you have any earings/piercings?
no
yes
Any scars on your body?
no
yes
Where:
Preferred type of Package or accommodation:
3*
4*
5*
my own choice
Period being considered for Travel: From
to
Loan Required?
no
yes
Enquiry:
Terms and conditions. -------------------------------------------------- By means of the present document the visitors or users of this Webpage are informed about the general conditions that prevail for its use or consultation. The use and/or consultation of this page implies on the part of the users, the acceptance of all the conditions that are written in this document. The user user commits itself to make use of the services that are offered in this page Web according to the law, with the general conditions that specified, as well as the generally accepted moral and good standing. The user commits itself to compensate José I García Ceballos of Mallorca Medical Group, for any prejudice or damage that could cause derived of the use of this Website infringing these general conditions and/or the current law. This document also gives information about the particular conditions that prevail for the hiring of the services that are offered. José Ignacio García of the Mallorca Medical Group has the right to modify the conditions that are written herein without previous warning TERMS & CONDITIONS Welcome to Mallorca Medical Group. 1. All surgical and medical act have an associated risk, sometimes unpredictable, including dissatisfaction with the result. 2. We encourage you to clarify any doubts that you might have prior to your intervention or procedure. 3. Our liability is limited to the duty of care as third party facilitator and we will not be held responsible for any medical procedure disputes. 4. In the event of a dispute the parties put themselves under the jurisdiction of the court of law of Palma de Mallorca renouncing explicitly to their own law in force at the place of the contract. 5. The quote for surgery that we will supply will include the procedure that you and the surgeon have agreed. 6. Our medical treatment quote includes: a. Pre-flight advice and third party services between yourself and the surgeon. b. Transfer from and to the airport in Palma de Mallorca and transfers between your accommodation and surgery for the agreed treatments and medical appointments. c. Pre-operative and post-operative consultations with your surgeon, the surgery and hospital accommodation in Palma de Mallorca. d. Telephone/ e-mail support before, during and after your treatment. e. If accommodation is booked via us you will be billed exclusively the booking fee. f. The final hotel/accommodation bill will be issued by the hotel/accommodation company at the agreed price together with any extra costs that you might have incurred during your stay and settled at the end of your hotel stay. g. Free trasnportation is only offered for those patients visiting Mallorca for the medical or surgical treatment agreed and for any accommodation within 5km away from our surgery in C/ Murcia, nº 40, Palma de Mallorca. Airplane or boat tickets might be requested a s a proof of arrival and departure. 7. Quotes are valid for a 30 days period. 8. Upon confirmation of your medical treatment and accommodation, if applicable, a deposit of 10% of the quoted price for surgery is required together the full amount required for the accommodation reservation, with a signed booking form. The balance is payable, a minimum of 2weeks prior to your treatment. In the event of cancellation of a booking made by the client the 10% deposit will not be refunded .The directors may waive this figure at their discretion. The Directors reserve the right to cancel a booking and refund any payments paid.Since the accommodation company might vary from client to client the reservation fees for this concept may or not be refunded according to the accommodation company policies. 9. Our Medical/Surgical Treatment quotation will not include airfares to and from Palma de Mallorca , any unforeseen complications that may arise from the Surgery or any other cause. An example of this is additional stay in hospital, further unplanned Surgery or consultations with other specialists. These unforeseen complications treatment needs are not limited to the given examples. 10. We will communicate with you by telephone, e-mail or fax in respect of the planned treatment, body photographs and your visit to Palma de Mallorca . Your personal data will be dealt under the current Spanish Data Protection Statutory law. You should read carefully the contents of the legal text below tilted Data Protection. 11. We will act as third party between the surgeon and yourself. 12. In the unlikely event of any medical complication after surgery, no additional surgical fees will be charged for a period of one year after the date in which your treatment is completely finalised. Surgical fees should be understood as those charged by the surgeon for the treatment of the complication. In no case they should include the cost of treatments that require various sessions to obtain the desired result, nor remaining costs involved such as hospital fees, anaesthesia, accommodation, flight or medications. 13. Medical and surgical advice given in this web site is intended to be accurate and to the best of our knowledge, however any advice given should be discussed and thoroughly understood with the surgeon before proceeding with treatments. 14. Transfers are provided free of charge for treatments which cost is 1000€ or above. Privacy Policy In conformity with the Spanish Personal Data Protection Statutory Law 15/1999 and by filling in the present form, you give your explicit consent to the use of your personal data. Your details will be inscribed in a file property of Mr José Ignacio García Ceballos registered in the General Registry of the Spanish Data Protection Agency. Your data could be use only for medical diagnostic, treatment planning and scientific document publication and medical education. The user gives his/her explicit consent to be sent marketing communications via E-mail or another way . We would like to inform you that you can make use of your right of accessing, rectifiying, cancelling, and opposing your data by sending a letter including a passport /DNI (Spanish residents), via registered mail to the following address, as it is established in the above mentioned Statutory law: Dr. José I García Ceballos Departamento de Atención al Cliente en relación a LOPD (Ley Orgánica de Protección de Datos) C/Murcia nº40 07014- Palma de Mallorca España
* I have read and accepted the Terms and Conditions:
Terms and conditions
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