BOOKING FORM

Once your case has been reviewed and please complete this form so we can confirm your appointment with your surgeon.

Name(required)

Email(required)

ID or Passport Number and Issuing Country(required)

Preferred Surgeon(required)

Procedures(required)

Preferred Consultation Date(required)

Preferred Surgery Date(required)

Emergency Contact Name and Relationship(required)

Emergency Contact Number/s (Include international code. Specify if mobile|landline|work)(required)

Emergency Contact Email

Preferred accommodation choice(required)

Arrival Detail: Flight Number | Date | Time (AM/PM)(required)

Departure Detail: Flight Number | Date | Time (AM/PM)(required)

Comment

Tick if you have read, understood and accept the disclaimer(required)

Thank you for completing the form, we will revert back to you as soon as possible.

Please email: cosmeticcliniccolombo@gmail.com if you need more details.

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Plastic & Cosmetic surgery, Non-surgical skin treatments BOTOX Filler Dental Implants Zirconia Crowns Emax Veneers

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