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					                                 Application Form
                    TEL.:+82-53-601-5386 FAX :+82-53-601-5078, 5372

* To book this program, please fill in the following information and send it to the 「Daegu Medical Tourism

  Marketing Support Center」via fax (82-53-601-5078, 5372) or E-mail (

* When your information has been processed, we will e-mail or call you a confirmation form.

1) PERSONAL INFORMATION (Please type or print CLEARLY.)
Title                     □Mr. □Ms.
First Name                                               Last Name
Birth (dd/mm/yy)                                         Passport No.
Contact Phone      -① +                                  Contact Phone -② +
Hotel Name                                               Hotel Room No.
2) RESERVATION DETAILS (Please indicate if you attending)
 Code       Medical Field          Checkup & Treatment Field         Date/ Time               Price
 Medical Tourism Program
                                                                        Nov.   ∎Hairs transplant $6,000
                                  □ Hairs transplant
 OP-1     Hair transplantation                                     □10th □11th ∎Eyebrows reconstruction
                                  □ Eyebrows reconstruction                      $3,000
                                                                                  ∎Oriental skin care $60~
                                 □ Oriental skin care                   Nov.
                                                                                  ∎Oriental medical checkup
 OP-2       Oriental Clinic      □ Oriental medical checkup        □10th □11th
                                 □ Oriental royal spa                   □12th
                                                                                  ∎Oriental royal spa $100~

                                                                                  ∎Male $350~
                                  □ Basic general check-ups                       ∎Female $450~
 OP-3      General Ckeckups                                        □10th □11th (Additional close examination
                                  □ Additional close examination
                                                                      □12th    : $120~)

                                  □ Scaling                             Nov.      ∎Scaling $80
 OP-4        Dental Clinic        □ Teeth whitening                □10th □11th ∎Teeth whitening $200
                                  □ Dental implants                     □12th     ∎ Dental implants : $1,500~

                                 □ Skin care                            Nov.   ∎Skin care $30~,
 OP-5                            □ Hair care                       □10th □11th ∎Hair care $40~
                 Clinic                                                        ∎Botox $200~
                                 □ Botox                              □12th
Remarks :
* If you want more detailed information about the medical field, Please contact or email us.
* The above information is subject to change depending on local circumstances.
* Prices may change depending on exchange rates.


On behalf of the persons named above, I have read, understood and accept the “Tour Conditions” as
printed below. I undertake to maintain contact with my booking source to ensure awareness of any
variations to tour costs and arrangements.

Name: ______________________________________ Date(dd/mm/yy): ______________

Signature: _______________________

* If you are unable to come for your scheduled tour, please contact 「Daegu Medical Tourism

Marketing Support Center」(+82-53-601-5386) no later than the day before your tour.

                                     Daegu Medical Tourism Marketing Support Center
                                      TEL +82-53-601-5386, FAX +82-53-601-5078, 5372