If you have decided that you would be interested in coming to South Africa for a medical procedure please complete the questionaire form below which will allow Jamandi to respond with detailed information for you to consider.
Name*
Surname*
Gender* Please Select Male Female
Nationality*
Email*
Contact Number:*
Date of Birth:*
Current Address:*
Allergies:*
Do you have any of the following:* High Blood Pressure Heart Disease Known Immune Disease Known allergy to local or general anaesthetics None of the Above
Are you on Cortisone or any other blood thinning medication?* Please Select Yes No
Susceptibility to keloids or difficulty with healing* Please Select Yes No
Are you:* Pregnant Trying to fall pregnant Breastfeeding None of the Above
Do you smoke?* Please Select Yes No
List any medication you currently take and dosage:*
Have you had any related procedures done before? Please provide details:*
Please indicate available/ preferred dates for procedure or surgery:*
From:*
To:*
Dental Procedures Teeth Whitening Dental Implants Porcelain, Veneers, Crown or Bridgework Other.
Cataract Surgery Retinal Repair Corneal Transplantation Strabismus Repair Glaucoma Surgery Eye Laser Procedures Other
Liposuction Please Specify area
Facial: Rhytidectomy/ Face Lift Mini or Full Blepharoplasty/ Eyelid Lower or Upper Rhinoplasty/ Nose Otoplasty/ Ear Setback Botox, Restylane, Perlane
Chest & Abdomen Breast Reduction Breast Augmentation Mastopexy/ Breast Lift Abdominoplasty/ Tummy Tuck
Knee & Hip: Replacement Arthroscopy Revision Correction of a fractured Hip, Limb or Joint
Hand & Foot: Removal of Ganglion, Bunions, Ingrowing Toenails, etc. Carpal Tunnel Syndrome Fractures Hammertoe
Yearly Executive Medical/ Health Check: This includes: Resting & Stress ECG, Chest X Rays, Lung Function Test, Eye & Hearing Screening, Blood Test for Cholesterol, Full Blood Count, Urea & Electrolytes, Liver function, Thyroid Function, Uric Acid, Fasting Glucose, Prostate, Pap Smear etc. Thorough Examination by a General Practitioner(Doctor). A medical History File to take home. (Mammogram and Bone Density can be arranged)
Please list any other procedures that you might be interested in: