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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

Full Legal Name (As Per Passport)*

Preferred Name*

Date of Birth:*

Day

Month

Year

Sex:*

Preferred Pronouns*

Contact Information

Address

Country/Region*

Address*

City*

Zip / Postal code*

Nationality:*

WhatsApp:*

Phone*

Email*

Occupation

Current Occupation:

Work Type:

Emergency Contact

Full Name:*

Relationship:*

Mobile Number:*

Email:*

Country:*

CRITICAL MEDICAL HISTORY & SAFETY SCREENING

Chronic Medical Conditions

Please select all that apply:

Hypertension

Diabetes

Heart Disease

Asthma

Thyroid Disease

Liver Disease

Kidney Disease

Autoimmune Disease

Sleep Apnea

Blood Clotting Disorder

Keloid Scarring

Chronic Pain Condition

Other

Details:

Current Medications

Medication Name:

Dosage:

Reason:

Frequency:

Blood Thinners:

Aspirin

Warfarin

Clopidogrel

Eliquis

Xarelto

Other

Hormonal Medications:

Oral Contraceptive Pill

Hormone Replacement Therapy

Testosterone Therapy

Other

Weight Loss Medications:

Ozempic

Wegovy

Mounjaro

Saxenda

Other

Vitamins & Supplements (Please select any supplements taken within the last 14 days):

Fish Oil

Omega-3

Vitamin E

Ginkgo Biloba

Ginseng

St John's Wort

Protein Supplements

Herbal Supplements

Other

Allergies

Antibiotics

Penicillin

Sulfa Drugs

Pain Medication

NSAIDs

Latex

Surgical Tape

Anesthesia

Food Allergy

Other

Reaction:

Previous Surgeries

Procedure:

Date:

Hospital:

Complications:

Family Medical History

Has any immediate family member experienced:

Anesthesia Complications

Blood Clots

Stroke

Heart Disease

Cancer

Genetic Conditions

Details:

Cancer History

단일 선택

YES

Cancer Type:

Year Diagnosed:

Treatment Completed:

Current Status:

Smoking History

단일 선택*

Never Smoked

Former Smoker

Current Smoker

Cigarettes Per Day:

Vape/Nicotine Use:

Date Able To Stop Before Surgery:

Alcohol Consumption

단일 선택*

Never

Occasionally

Weekly

Daily

Recreational Drug Use

단일 선택*

YES

Female Patients Only

단일 선택

Pregnant

Breastfeeding

Planning Pregnancy

Not Applicable

Recent Cosmetic Treatments (Past 12 Months)

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Botox

Fillers

Thread Lift

Ultherapy

Thermage

Onda

InMode

Titanium

Density

Rejuran

Juvelook

Exosome

Other

Treatment Dates:

TREATMENT GOALS & EXPECTATIONS

Top 3 Concerns

Top 1*

Top 2

Top 3

Desired Outcome

Describe your ideal result:

Preferred Style

다중 선택

Natural

Balanced

Trendy

Dramatic

Reference Photos

Desired aesthetic examples:

Previous results you like:

Celebrity photos:

Treatment Timeline

단일 선택*

Within 1 Month

1–3 Months

3–6 Months

6–12 Months

Researching Only

Recovery Preference

단일 선택*

Minimal Downtime

Moderate Downtime

Extended Recovery Acceptable

Best Results Regardless of Recovery

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.

Preferred Materials:

Silicone

Ear Cartilage

Septal Cartilage

Rib Cartilage

Donor Rib Cartilage

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.

Dental Implants

Full Mouth Implants

All-On-4

All-On-6

Veneers

Zirconia Crowns

Ceramic Crowns

Smile Makeover

Teeth Whitening

Invisalign

Braces

Sedation Dentistry

Other

SKIN & AESTHETIC TREATMENTS

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

Botox

Fillers

Ultherapy

Thermage

Onda

Titanium

InMode

Density

Rejuran

Juvelook

Exosome Therapy

Laser Treatments

Pigmentation Removal

Tattoo Removal

Scar Revision

Hair Removal

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

드롭다운

Existing Diagnosis

Please provide details:

BODY MEASUREMENTS

Height (cm):*

Weight (kg):*

BMI:

Breast Surgery Patients

Current Bra Size:

Desired Cup Size:

Body Contouring Patients

Waist Circumference:

Hip Circumference:

CONCIERGE & TRAVEL PLANNING

Service Package Selection

Please select your preferred service package:*

Standard Medical Tourism

VIP Medical Tourism

Standard Medical Tourism

Medical coordination and treatment arrangements only.

VIP Medical Tourism

Full concierge support including travel planning, accommodation assistance, recovery coordination, and personalised patient support.

Flight Preferences

드롭다운*

Mileage Upgrade Assistance

YES

Accommodation

드롭다운*

Travel Companion*

YES

Number of Companions:

Dietary Requirements

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Halal

Vegan

Vegetarian

Gluten-Free

No Seafood

Other

Tourism Interests

다중 선택

Luxury Shopping

K-Beauty Experience

Traditional Culture

Fine Dining

Golf

Wellness Retreat

Interpreter Requirement

Recovery Assistance

드롭다운*

Estimated Travel & Accommodation Budget

(Excluding Medical Costs)*

AUD $5,000

AUD $10,000

AUD $20,000+

Custom Budget

MEDICAL PHOTO UPLOAD GUIDE

Eyes (4 Photos)

Front View (Relaxed)

Front View (Eyes Open Wide)

Eyes Closed

45° Side View

Nose (5 Photos)

Front View

Left Profile

Right Profile

45° Side View (Left)

45° Side View (Right)

Face & Skin (3 Photos)

Front View

45° Side View

Side Profile

Body (3 Photos)

Front View

45° Side View

Side Profile

Dental (3 Photos)

Full Smile

Mouth Open

Existing X-Rays

REFERRAL & CONSULTATION INFORMATION

How Did You Hear About Us?*

Google

Instagram

TikTok

Facebook

YouTube

Referral

Existing Patient

Event

Chatgpt, Gemini, Claude

Other

What Is Most Important To You?*

Safety

Surgeon Reputation

Natural Results

Fast Recovery

Price

Luxury Experience

Aftercare Support

Additional Comments & Requests

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.

Patient Name:*

Date:*

Signature*

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