Intake Form

Intake Form

Patient Consultation - Secured

Name on passport*
First Last
Country (Passport)*

Which country passport do you hold?
Gender (Sex)*
Height
Weight
Date of Birth*
MM slash DD slash YYYY
When are you planning to come arrive in Korea?
MM slash DD slash YYYY

If you don't know the exact date yet just choose and approximate date.
Occupation*
Address*
Street Address Address Line 2 City State / Province / Region Country
Phone*
Email*
Enter Email Confirm Email
Have you had surgery before in areas you want to treat?*
- Yes
- No
Prior Surgery Medical History*
Have you had surgery before? Do have a medical condition your doctor should be aware about. Please be as detailed as possible.
What is your current concern or aesthetic goal?
Please tell us what you would like the doctor to know and what your current concerns are about your appearance?
Do you have any specific clinics in mind? If you leave this blank we will help match you with clinics best suited for your case.
Special Note
Photos
Drop files here or

Max. file size: 10 MB, Max. files: 4.
Please add photos such as front, side and 45 degree angle.
Disclaimer: The content on this website is solely for informational and educational purposes. Information provided on this website should not be considered medical advice and is not a substitute for consultation with a qualified medical professional. Communications to or from clinics, doctors, users and My Seoul Secret staff (ASTUTR CO., LTD.) and any person will not be considered to establish a patient/doctor relationship until an actual face-to-face diagnosis, treatment and necessary paperwork is processed on-site at a medical clinic.*
- I agree and understand
You cannot submit this form if you do not agree. If you do not agree, please exit this webpage.

Patient Consultation - Secured

My Lip Surgery at Deesse Plastic Surgery (Cheongdam Godess)

Decision to do liposuction with 365mc Clinic

Facial Contouring and Rhinoplasty in DA Plastic Surgery (Seoul)

My first Experience of Lipo at 365mc in Korea

Korean American Eyelid Surgery in Seoul

About us

Connect To Us