Enquiry Form

Anti Aging, Hormone Therapy, Cancer And Health Screening.

Hormone Therapy, Genetic Profiling, Anti Aging, Pregnancy And Infertility Treatment, Cancer And Health Screening available at PrimaNora Medical Centre

HOW PRIMANORA CAN HELP YOU SOLVE YOUR HEALTH AND BEAUTY CONCERNS

Name:
Age:
Telephone No:
Email Address:

You can choose more than one issues in every section.HEALTH ISSUES
	I want to know how to reduce risks of cervical cancer, breast cancer, ovarian cancer and other woman’s cancer.
	How can I prevent getting a heart attack?
	I am worried about menopause; I think I have the symptoms.
	I am concerned about my weight.
If others, please specify

SKIN REJUVENATION
	My skin is dry and rough, what do I do?
	How can I have a clear, bright and glowing face?
	How can I have fresh-looking, rejuvenated and hydrated skin?
	My acne embarrasses me, what can be done?
	How can I have a fairer looking skin?
If others, please specify

FACE COMPLEXION
	I want my skin to look more youthful and smooth with smaller pores.
	How can I prevent my face from sagging and have firm and lifted face without surgery?
	I want less fine lines and wrinkles on my face.
	What can I do to lighten my pigments on my face?
	I do not like my acne scars, please remove it for me.
If others, please specify

BODY CONTOURING
	I want to reduce the cellulite on my thighs/buttocks.
	I want to have a shapelier, firmer and more toned body.
	How do I get rid of my ‘bat-wings’/flabby arms?
	How do I reduce the fat around my waist line?
	My buttocks are sagging, lift it up for me.
If others, please specify

HAIR REMOVAL
	I do not like the moustache on my face.
	I do not like the hair on my arms and legs.
	I want smooth and fairer-looking armpits.
	I want to remove my unwanted body hair permanently without pain.
If others, please specify

PrimaNora Medical Centre can contact me:

On the following day:
	Any day
	Weekday
	Weekend

At the following time (Malaysian time):
	Between 9.00am – 12.00pm
	Between 12.00pm – 3.00pm
	Between 3.00pm – 6.00pm
	After 6.00pm

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