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avaé Medical Tourism Pre-Consultation

Confidential Medical Information

Please complete this form as accurately as possible. The information provided will be reviewed by surgeons, dentists, physicians, anesthesiologists, and medical coordinators to determine your suitability for treatment and provide an accurate preliminary assessment.

PATIENT PROFILE

Personal Information

Date of Birth:
Day
Month
Year
Sex:
Preferred Pronouns

Contact Information

Address

Occupation

Work Type:

Emergency Contact

Passport Status

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Valid Passport
Need Renewal
Applying for First Time

Visa Requirement

Do you require visa assistance for entering South Korea?
Yes
No

CRITICAL MEDICAL HISTORY & SAFETY SCREENING

Chronic Medical Conditions

Please select all that apply:

Current Medications

Blood Thinners:
Hormonal Medications:
Weight Loss Medications:
Vitamins & Supplements (Please select any supplements taken within the last 14 days):
Allergies

Previous Surgeries

Family Medical History

Has any immediate family member experienced:

Cancer History

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YES
NO

Smoking History

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Never Smoked
Former Smoker
Current Smoker

Alcohol Consumption

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Never
Occasionally
Weekly
Daily

Recreational Drug Use

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YES
NO

Female Patients Only

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Pregnant
Breastfeeding
Planning Pregnancy
Not Applicable

Recent Cosmetic Treatments (Past 12 Months)

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TREATMENT GOALS & EXPECTATIONS

Top 3 Concerns

Desired Outcome

Preferred Style

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Reference Photos

Desired Travel Timeline to Korea

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Within 1 Month
1–3 Months
3–6 Months
6–12 Months
Researching Only

Recovery Preference

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Minimal Downtime
Moderate Downtime
Extended Recovery Acceptable
Best Results Regardless of Recovery

Recovery Flexibility

What is the maximum time you can stay in Korea for recovery?
7 Days
14 Days
21 Days
30+ Days

PLASTIC SURGERY

Eye Surgery

Please select any procedures you would like to discuss during your consultation.

Rhinoplasty

Please select any procedures you would like to discuss during your consultation.

Facial Contouring

Please select any procedures you would like to discuss during your consultation.

Facelift & Anti-Aging

Please select any procedures you would like to discuss during your consultation.

Breast & Body

Please select any procedures you would like to discuss during your consultation.

DENTAL TREATMENT

Please select any procedures you would like to discuss during your consultation.

SKIN & AESTHETIC TREATMENTS

Please select any treatments you would like to discuss during your consultation.

REGENERATIVE MEDICINE & WELLNESS

Stem Cell Therapy

Please select any treatments or procedures you would like to discuss during your consultation.

Longevity & Wellness

Please select any treatments you would like to discuss during your consultation.

Primary Health Goal

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Existing Diagnosis

BODY MEASUREMENTS

Breast Surgery Patients

Body Contouring Patients

CONCIERGE & TRAVEL PLANNING

Service Package Selection

Please select your preferred service package:
Standard Medical Tourism
VIP Medical Tourism
Ava Private Medical Tourism

Standard Concierge

Medical coordination and treatment arrangements.

VIP Concierge

Full concierge support with dedicated local assistance.

Ava Private Concierge

Exclusive founder-led concierge with Ava's direct 1:1 support.

Flight Preferences

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Accommodation

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Dietary Requirements

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Tourism Interests

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Interpreter Requirement

Recovery Assistance

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드롭다운

Budget Breakdown

Estimated Medical Budget;
Under AUD $5,000
AUD $5,000
AUD $10,000
AUD $20,000+
Custom Budget
Estimated Travel & Concierge Budget:
Under AUD $3,000
AUD $3,000 - 5,000
AUD $5,000 - $10,000
AUD $10,000+
Custom Budget
Will your travel companion also be seeking medical or aesthetic treatments?
Yes
No
Maybe

MEDICAL PHOTO UPLOAD GUIDE

Eyes (4 Photos)

Nose (5 Photos)

Face & Skin (3 Photos)

Body (3 Photos)

Dental (3 Photos)

REFERRAL & CONSULTATION INFORMATION

Decision Readiness

Which of the following best describes your current stage?

Medical Tourism Priority Ranking

Please prioritize the following factors for your medical journey (1 being the most important)

1st Priority (Most Important)
2nd Priority
3rd Priority
4th Priority
Have you already contacted or consulted with any Korean clinics or other agencies?
No, I haven't contacted anyone yet.
Yes, I have contacted clinics directly.
Yes, I am speaking with another medical tourism agency.
How Did You Hear About Us?
What Is Most Important To You?

PATIENT DECLARATION

I confirm that the information provided in this form is true and accurate to the best of my knowledge. I understand that failure to disclose medical history, medications, allergies, or previous procedures may affect treatment recommendations and patient safety.

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