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Introduction
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Booking Form
MEDICAL FORM
ENQUIRY FORM
OVERVIEW

BOOKING FORM

Please complete the following form for your holiday and treatments in Malaysia. Please give as much information as possible in all cases, especially your health and medical history. All people having surgery is required to fill in the following forms.

All bookings must be accompanied by payment for accommodation, which can be paid by direct transfer (telegraphic transfer through bank).

Payment for all surgery and dentistry treatments is payable direct to the hospital after the consultation with the surgeon, when you are happy and agree to go ahead with your surgery.

Please take note, IMPORTANT!
Payment for your surgery to the hospital has to be made in Cash or Credit Card. If you are doing bank transfers, the money has to be cleared 7 days before your surgery day. If your payment is not available on surgery day, your surgery will be cancelled or postponed. Please note we do not accept personal cheques.

*Required fields. Please fill in data before submitting.

First Name (As per passport)*
Last Name (As per passport)*
Email Address*
Secondary Email Address (if any)
Telephone
Mobile Phone
Street Address
City State/Province
Postcode
Country*
Date of Birth (DD/MM/YEAR) Age*
Name of Next of Kin
Next of Kin Contact (Email Address or Mobile Phone)
Relation of Next of Kin
Would you like to update this person after your surgery? Yes, please contact.
Passport Number

Who is the surgeon and hospital you would like to book with?
Your Surgery Treatments
If your desired treatment is not in the above list, please state here

Accommodation/Hotel
Hotel - Number of Nights
Your Itinerary - if staying in different hotels, please give details and dates
Number of Adults
Number of Children
Name of Other People Travelling
Arrival Date
(DD/MM/YEAR)
Departure Date (DD/MM/YEAR)
Number of Nights
Flight Arrival Time Airline & Flight Number
(Arrival)
Flight Departure Time Airline & Flight Number
(Departure)
Do you have any other enquiries or requests?

Visa Mastercard Bank Transfer (please refer below)
For bank transfer
(Asia Pacific)
Please transfer to:
HSBC Bank in Malaysia
Account name: Lipocity Sdn. Bhd.

Swift code:HBMBMYKL
Bank Address: Ground Floor, Wisma UEP, Jalan USJ 10/1A, 47620 Subang Jaya, Selangor, Malaysia.
Account number: 352-193544101

Please state clearly your name in the reference when transferring.
For credit cards
*
Please authorize a credit card charge of 1.5% for all credit card charges. If you don't choose to pay the charge, please do a direct transfer by your bank account.
Name on card
Card Number
Expiry Date
+1.5% credit card fees*
What are you paying for Accomodation Package
*Deposit For Hospitalization/Surgery
Amount (As advised to you by your Sales Manager)

If you haven't already, please provide photos to: customerservice@lipocity.com

   

About Us
Introduction
Our Pledge
History
Our Community Work
Recuperating Services
Transportation Services
Destination
Introduction
Kuala Lumpur
Ipoh, Perak
Malacca
Sarawak
Procedure
Surgical Procedures
Non-Surgical Procedures
Surgery Costs
Preconditions & Risks
Client
Testimonials
Products
Breast Implants
Compression Garments
Scar Treatment Products
Men's Health Products
Promotion
Latest Promotion
Book & Plan
Overview
Enquiry Form
Medical Form
Booking Form
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