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Please complete the following form for your holiday and treatments. Please give as much information as possible in all cases, especially your health and medical history.

All people having surgery are required to fill in the following forms. If you are travelling with another person who is having surgery, please ensure that you forward this form for them to fill in.

All bookings must be accompanied by payment for accommodation, which can be paid by credit card or direct transfer. 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.


Cheap Flights

Swift Code: BKKBTHBK
622 Emporium Tower Sukhumvit Rd. Khlong Tan Khlongtoei Bangkok 10110

Booking Form
  * please complete all fields
First Name:
Last Name:
Email:
(Important: Our response to you may be directed to your 'junk' or 'spam' folder. Please provide an alternative address if you have one. Otherwise, please add Mediseekers to your safelist)
2nd email address if you have one:
Phone:
Mobile Phone:
Street Address:
City:
State/Province:
Postcode:
Country:
Date of birth: (day/month/year)
Age:
Next of Kin:
Relationship to you:
Next of Kin (Email/Phone):
Where did you hear about us?
Your Surgery:
Choose Destination:

Hints for choosing the right location

Bangkok only: Cheapest option. 

Clients booking for Kanchanaburi and Hua Hin will be treated first in Bangkok.

Kanchanaburi: Peaceful. Relax by the river and experience nature.
Hua Hin: Enjoy this peaceful beach close to Bangkok.
Kanchanaburi + Hua Hin: Get the best of both worlds.
Phuket: Chill out with the ocean breeze on this beautiful island. Most expensive option. You will be treated at Phuket Hospital.


Choose Surgery/Treatments:

Choose your treatment(s) from the list below.

Liposuction (Fat reduction)
Breast Augmentation
Eyelid Surgery (Bhlepharoplasty)
Nose Augmentation Surgery (Rhinoplasty)
Nose Reduction Surgery (Rhinoplasty)
Tummy Tuck (Abdominoplasty)
Face Lift
Mommy Makeover
Breast Reduction
Breast Lift
Breast Implant Correction
Pouty lips (Lip Augmentation)
Designer Vagina (Labiaplasty)
Buttock Lift
Ear Surgery
Chin Augmentation
Gastric Banding
Hair Transplant
Snoring Reduction
Optic (Lasik Eye Correction surgery)
Dental
Hearing Aids
Contact Lenses
Thermage (Natural Facelift)
Mesotherapy (Weight Loss/Cellulite Reduction)
Botox
Laser hair removal
Restylane (Wrinkle Filler)
Microdermabrasion (Skin Rejuvenation)
Chemical Peel (Skin Rejuvenation)
Tattoo/Mole/Varicose Vein Removal
Detox
Orthopaedic
Knee Surgery
Spine Surgery
Cardiac (Heart)
Neurological (Gamma Knife)
Bariatric (Obesity - Gastric Banding)
Eye (Lasik Surgery)
Health Check up / MRI/PET/CT Scans
If not on the list above, please list the treatments that you would like:

If you haven't already, please attach photo of the area to be treated here:
If your surgery treatments are not listed above, please list your surgery and other treatments (dentistry, optical etc.):
What are your personal goals of having surgery?
Your Holiday: 
What is the Holiday Accommodation Package you would like to book: Budget Value Luxury Elite
Number of Adults travelling:
Number of Children travelling:
Name of other people travelling:
Arrival date (DD/MM/YEAR):
Departure date (DD/MM/YEAR):
How many days:
Flight arrival time:
Flight arrival airline and number:
Flight departure time:
Flight departure airline and number:
Do you have any other questions or requests?
Medical Form 

Please fill in the medical questions below. It is important to be very thorough in your replies, listing any medical or psychological history, medication and allergies.

Your full name:
Age:
Your height (feet or cm)
Weight (pounds or kgs)
Do you smoke?

Have you had, or been treated for any of the following: (Please check YES or NO)

anemia
asthma
blood clots/deep vein thrombosis
blood pressure
blood disorders
bleeding disorders
breathing problems
diabetes
Hepatitis
AIDS or HIV
epilepsy
heart problems
kidney problems
nose/throat problems
stomach problems
thyroid problems
psychiatric illness
depression
drug dependence
Are you pregnant?
Do you take the Pill?
If you answered "YES" to any above, can you please detail further:
Any condition not listed?
Any medication not listed?
Any reactions to local or general anesthetic?
Any scarring problems?
How would you describe your general health - including diet and fitness?
For optical treatments:
Do you currently wear glasses?
What is your prescription:
Do you have any problems with your eyes eg. Dry eyes:
Please confirm that you have read and agreed to the risks of plastic surgery
Do you have any final requests or questions?

If you haven't already, please provide photos to: info@mediseekers.com
Next Step: Read and agree with the Terms and Conditions of Booking

 

Terms and Conditions and important notices fromMediseekers

Mediseekers trades under the name Anglian International Co., Ltd.

It is compulsory to read and state that you have read and agreed to the terms and conditions below:

This document sets out the contractual terms and conditions in relation to the services provided to you by Anglian International Co., Ltd. ("Mediseekers " or "Us").

By making any enquiry or booking with Mediseekers , you ("You"  or "I") agree to be bound by these terms and conditions.

Mediseekers strongly urges you to read the Disclaimer of Responsibility below and if you do not understand it, to seek your own independent legal advice.

If any information provided by or on behalf of Mediseekers is inconsistent with these terms and conditions, then you agree that these terms and conditions prevail to the extent of any inconsistency.

What services will Mediseekers provide?
Anglian International Co., Ltd. (Mediseekers) is a British owned company based in Thailand that:

  • books hotels (herein referred to as the "Hotel Booking Services"); and
  • books elective plastic surgery, dentistry and optical procedures (herein referred to as the "Elective Surgery Booking Services").

Incidental goods and services may be provided or booked on your behalf in connection with Hotel Booking Services and Elective Surgery Booking Services.

For the purpose of these terms all elective surgery, dentistry and optical procedures will be referred to as "Elective Surgery Procedures" and all bookings made for accommodation on your behalf at hotels are referred to as "Hotel Services".

Important term: Other than making information from third parties available to you, introducing you to third party providers of goods and services, and booking, Mediseekers is not itself providing you with any goods or services in the capacity of a principal, agent or sub-contractor. 

Important term: Third party principals (who are not agents of or not sub-contractors to Mediseekers will provide all goods and services to you (including travel, activities, meals, consultations, operations and procedures that may have been booked by Mediseekers on your behalf).

Whilst Mediseekers will use its best endeavours to exercise every reasonable care in the selection of the third parties to whom you are introduced and who may provide the goods and services to you, Mediseekers shall not be liable to you in any way whatsoever for any damage, loss or injuries which you may suffer arising from or in relation to the goods or services provided by these third parties to you.  It is important to note, therefore that:

(a)  Mediseekers’ role is merely to introduce suppliers of those goods and services to you and Mediseekers does not make any express or implied representation or warranty that any goods or services supplied by third parties to you will be fit for your required purpose or supplied by them with reasonable care and skill; and

(b)   the goods and services to be provided by third parties are subject to the terms and conditions and limitations of liability as may be separately imposed by the third parties (namely, the hospitals, clinics, hotels and other providers of goods and services to you, some of which limit or exclude liability in respect of death, personal injury, delay and loss or damage to baggage).

What is the procedure before and after I arrive in Thailand?

At the time of payment for your accommodation, Mediseekers will book all hospital, clinic appointments (as the case may be) and hotel accommodation and transfers.

During your stay in Thailand, you will be assisted by a representative from Mediseekers’ associate company in Thailand, who will provide the pick-up and transfer at the airport at a prearranged time.
On the day following your arrival you will have an appointment with the nominated Surgeon for a pre-operative consultation (Surgeon Consultation).

Within 48 hours of the Surgeon Consultation and provided that the Surgeon and you agree to proceed with the Elective Surgery Procedures, you will be admitted to the Hospital for the purpose of undergoing the Elective Surgery Procedure. 
Following the Elective Surgery Procedure, you will remain in the Hospital for an observation period and post operative consultations as required by the Surgeon.

At an appropriate time (as determined by the Surgeon), you will be discharged from the Hospital and return to your hotel.  The Surgeon will recommend a period of time that you should remain in Thailand for recuperation.
Mediseekers will use their best endeavours to ensure that the representative from Mediseekers’ associate company in Thailand is contactable 24 hours a day during the time you are in Thailand. If you would like to add, change or cancel any treatments, please give at least 48 hours notice to the representative.

This process described above may vary from patient to patient.

What is the purpose of the Surgeon Consultation?

The Surgeon Consultation serves a number of purposes.  These include the following.

  • The Surgeon Consultation will help the Surgeon determine the appropriateness (from a medical perspective) of each Elective Surgery Procedure you wish to undergo. 
  • The Surgeon will take the opportunity to explain the surgery and the procedure. The Surgeon will also inform you of any form or consent which the hospital may require from you or to be signed by you..
  • To give you the opportunity to meet the Surgeon and ask any questions you may have.
  • To give you the opportunity to decide and confirm whether to go through with the Elective Surgery Procedure.
  • In addition, the Surgeon will determine if any additional procedures are required that will add to the cost as set out in the Pre-Consultation Price Estimate.

Both you and the Surgeon are under no obligation to proceed with an Elective Surgery Procedure at any time.

How will Mediseekers advise me of the price for Elective Surgery Procedures?

The price for Elective Surgery Procedures is determined in two stages:

Stage 1: Based on the information provided by you to Mediseekers, we will make enquiries with third parties for the purpose of giving you an estimate of the price for Hotel Services and Elective Surgery Procedures.  This estimate is herein referred to as the "Pre-Consultation Price Estimate" (the price for Hotel Services and Elective Surgery Procedures will be separately itemised).

Stage 2:  Following your arrival in Thailand, you will be required to attend the Surgeon Consultation.  Following the Surgeon Consultation, the final price for Elective Surgery Procedures will be determined, (the "Final Price Amount").

When the Final Price Amount is decided and agreed by you, you will pay the amount directly to the hospital in accordance with the terms of payment of the hospital – before surgery.

What goods and services are included in the Pre-Consultation Price Estimate?

The Pre-Consultation Price Estimate will include each of the services specified below:

(a) Hotel Services: The estimated price for Hotel Services, which may include (subject to your required package) the following:

  • Accommodation at a specified hotel;
  • Transfer from Bangkok or Phuket airport to your hotel and return to the same airport;
  • Transfers from your hotel to the hospital and return to the hotel for the initial consultation, the elective procedure and at least two further visits to the hospital for post operative attention; and
  • Meals (if you elect for meals to be included in your package).

(b) Elective Surgery Service: The estimated price of each Elective Surgery Procedure and the related On Cost (as defined below) for that particular procedure.

Important note:  You acknowledge and accept that the estimated price of each Elective Surgery Procedure is only an estimate and is subject to changes or variations after the Surgeon Consultation. 
Unless otherwise specified in your Pre-Consultation Price Estimate, the "On Costs" for each Elective Surgery Procedure includes:

  • One Surgeon Consultation;
  • The services of the Surgeon for the purpose of carrying out the selected a Elective Surgery Procedure(s);
  • The services of a specialist anaesthesiologist (if required);
  • Post operative accommodation at the private clinic/hospital for the specified period of time for the required procedure;
  • All theatre charges for carrying out the required procedure;
  • General medication required immediately following post operation,
  • Post-operative consultation prior to your departure from Thailand.

It is not possible to determine the exact price of Elective Surgery Procedures without first having the Surgeon Consultation (as discussed above).

What goods and services are excluded in the Pre-Consultation Price Estimate and the Final Price Quote?

The following goods and services are excluded from the Pre-Consultation Price Estimate and the Final Price Amount:

  • Any additional medical expenses that might be incurred following any Elective Surgery Procedure as a result of unforeseen complications or as may be included in the Final Price Amount.
  • Travel insurance and / or any medical insurance (see discussion below).
  • Any procedure for which an estimate is not given in respect of in Pre-Consultation Price Estimate and the Final Price Quote.
  • Tours or outings.
  • Any time spent at a hotel in excess of the departure date specified in the Pre-Consultation Price Estimate and the Final Price Amount.
  • Additional expenses not specified in the Pre-Consultation Price Estimate and the Final Price Amount.
  • Meals (unless they are specified in the Pre-Consultation Price Estimate and the Final Price Amount as being included in the price).
  • Air tickets (or other transport) to/from Thailand.
  • Airport or departure taxes, road tolls, laundry, beverages, gratuities or tips.
  • Additional costs incurred by weather or failure of transport services or other circumstances beyond the control of Mediseekers.

How long is the Pre-Consultation Price Estimate valid for?

The Pre-Consultation Price Estimate is valid for 21 days from the date on which it is given to you, or an earlier date if advised by Mediseekers.

Can the final price vary from the price in the Pre-Consultation Price Estimate and the Final Price Quote?

Yes. For example:

  • Pre-Consultation Price Estimates are expressed in a specified currency and reflect anticipated exchange rates unless otherwise indicated. Prices are subject to review (and change) as Mediseekers, the relevant hospital or hotel may advise.
  • As discussed above, the Elective Surgery Procedures may vary following the Surgeon Consultation.
  • All credit card payments are subject to exchange rate fluctuations, determined by your issuing bank.

What are the terms of payment?
If you wish to use the Hotel Booking Service and Elective Surgery Booking Service, the following procedure applies:

  • Confirmation of Pre-Consultation Price Estimate: Mediseekers will confirm that the Pre-Consultation Price Estimate is correct, that prices for Hotel Services and Elective Surgery Procedures have not varied and that your requested dates remain available.
  • Pay for Hotel Services and any flights: After Mediseekers gives you confirmation of the Pre-Consultation Price Estimate and confirms availability of requested dates, then you can book the Hotel Services and Elective Surgery Procedures as set out in the confirmed Pre-Consultation Price Estimate by paying for a sum as may be specified by Mediseekers [the total booking price excluding the surgery costs]. See the ‘Important Terms’ below regarding the non-refundable conditions attached to the booking. 
  • Pay for Elective Surgery Services:  After the consultation, when costs have been confirmed by the surgeon and agreed by you, you will pay for the surgery procedures direct to the hospital. You shall pay the hospital directly for your Elective Surgery Procedure, your stay at the hospital and all other costs in relation thereto in accordance with the terms of payment of the hospital. 

Important term: You acknowledge and agree that the booking is non-refundable to you in any circumstances.

What happens if after the Surgeon Consultation, I decide not to proceed with any surgery or the Surgeon refuses to perform a particular procedure?

If, following the Surgeon Consultation, the Surgeon or yourself elects not to proceed with the Elective Surgery Procedure, none of that amount paid for the Hotel Services will be refundable to you.

Important term:  When booking the holiday and procedure, it is important that you understand that the price and dates specified for consultation, procedures and recovery time are set out in the Pre-Consultation Price Estimate.  You acknowledge and agree that Mediseekers is not responsible for organising any travel to or from Thailand.  Accordingly, you are responsible for ensuring that you are able to arrive and depart on the dates specified in the Pre-Consultation Price Estimate.

What happens if I wish to vary my booking?

Following the payment of your accommodation, you may amend your dates of travel, subject to any administration fees and any surcharges or fees imposed by the hotel in respect thereof. But, note that the booking is non-refundable and the accommodation elements may not be cancelled.

Do I need a passport or visa for Thailand?

Mediseekers is not a travel agent and does not provide advice in relation to visa or passport requirements for Thailand.
It is your responsibility to make sure all required travel documents when entering Thailand are valid and correct.

Do I need to take out my own travel and medical insurance?

Yes.  Mediseekers does not include any insurance in the cost of the Hotel Services or Elective Surgery Procedures.

Accordingly, Mediseekers strongly recommends that you take out travel insurance, so that you will be comprehensively insured for your travel. Subject to your requirements, Mediseekers recommends that you take out travel insurance that covers you against cancellation fees and loss of deposits, emergency medical, overseas medical and hospital expenses, theft, luggage delay, travel delay, personal liability and car rental excess.

Certain travel insurance may not cover you for costs incurred as a result of elective surgery or medical malpractice in connection with elective surgery.  Mediseekers recommends that you consider obtaining specialist insurance for this purpose. 

Mediseekers strongly recommends that you disclose all relevant matters to your insurer (including the fact that you may be undertaking elective surgery as part of your travel).

Important term:  You acknowledge that Mediseekers has not offered you any insurance or advice in relation to a particular insurance product.  You have reviewed the terms of your insurance policy (if any) and are satisfied that it provides you with the level of insurance you consider that you require.

Is a surcharge payable if I use a credit card to pay for my booking?
Yes.  Mediseekers will charge you an amount equal to 1.75% of the cost of your booking if you use a credit card to pay.

Limitation of Responsibility and Liability

Mediseekers provides the Hotel Booking Service and Elective Surgery Booking Service only.  Other than making information from third parties available to you, introducing you to third party providers of goods and services, organising tickets and facilitating payment of goods and services by you to third parties, Mediseekers is not itself providing you with any goods or services in the capacity of a principal.  Third party principals (not sub-contractors to Mediseekers) provide all goods and services to you (including tours, travel, activities, meals, consultations, operations and procedures).

Whilst Mediseekers will use its best endeavours and exercises every reasonable care in the selection of third parties to whom you are introduced and who may provide goods and services to you in connection with a tour, it is important to note, that:

(a)  Mediseekers’ role is to merely introduce you to the supplier of those goods and services and Mediseekers does not make any express or implied representation or warranty that any goods or services supplied by third parties to you will be fit for your required purpose or supplied by them with reasonable care and skill; and

(b)   the goods and services to be provided by third parties are subject to the terms and conditions and limitations of liability as may be separately imposed by tour operators, airlines, hospitals, clinics, dentists, hotels and other providers of goods and services to you (some of which limit or exclude liability in respect of death, personal injury, delay and loss or damage to baggage).

Neither Mediseekers nor any of its officers, employees or directors are doctors, dentists or otherwise are qualified to provide information in relation to any Elective Surgery Procedure. You acknowledge and accept that Mediseekers (or any of its officers, employees or directors) has not offered any advice or expressed any opinion that a reasonable person would consider as being an advice or opinion in relation to any medical procedure or Elective Surgery Procedure (including any risks, side effects or otherwise).

Mediseekers does not accept any liability of whatever nature for the acts, omissions or default, whether negligent or otherwise, of tour operators, airlines, hospitals, doctors, clinics, dentists, hotels and other providers of goods and services to you directly or indirectly in connection with any goods and services booked by Mediseekers on your behalf.

Without limiting the provisions of this clause, you agree to be bound by the terms of any contract between a third party provider of goods and services and yourself (which may be evidenced in writing by the issue of a ticket, voucher, coupon confirmation or the like). 

Mediseekers does not accept any liability in contract or in tort for any injury, damage, loss, delay, additional expenses or inconvenience caused directly or indirectly by force majeure or other events which are beyond our control, or which are not preventable on our part.

What is the governing law of these terms and conditions?
Any contract for:

  • Hotel Booking Services; and/or
  • Elective Surgery Booking Services

provided by Mediseekers in accordance with the terms hereof is deemed to be made in Thailand and any disputes shall be dealt with within Thailand and you agree to submit to the jurisdiction of the Courts of Thailand. 

Any provision of, or the application of any provision of, these terms and conditions which is void, illegal or unenforceable in any jurisdiction does not affect the validity, legality or enforceability of that provision in any other jurisdiction or of the remaining provisions in that or any other jurisdiction.
I agree that I have read, understood and agreed with the Terms and Conditions from Mediseekers

I agree with the Terms and Conditions.

 
 
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