Avora Intake

This intake helps us understand your situation before your review.
This is just our introduction to ensure your scenario and our services are a good match. You do not need to be thoroughly detailed at this point.
Take your time — you don’t need perfectly organized answers.

What to expect:

• Takes approximately 10–15 minutes
• Helps us prepare for your Clarity review
• This is not emergency or medical care
• Your information is reviewed confidentially

Blank Form (#3)

Safety & Fit Check
Who This Is For
What This Has Felt Like
Your Story (In Your Own Words)
Timeline & Care Snapshot

Before we begin, please review the following:

I understand Avora is not an emergency or urgent medical service.
I am not currently experiencing a medical emergency (such as chest pain, stroke symptoms, or thoughts of harming myself).
I understand Avora does not diagnose, prescribe, or provide medical treatment.
I understand Avora does not replace my doctors or medical providers.
I am not seeking legal opinions, medical judgments, or documentation for a legal or insurance case.

Agreement

I agree

If any of the following apply, please check and briefly explain:

My situation is urgent

I am currently involved in a legal, disability, workers’ compensation, or insurance claim related to my care

None of the above apply

Optional explanation (if checked above)

This helps us understand consent, communication, and how to share information.

I am completing this form as:

The patient

A caregiver or advocate

Other (please explain)

Please explain

Do you have permission to share and review medical information?

Yes

Unsure

Who should receive written summaries or communication from Avora?

The patient

Both

These statements describe common experiences people have when care feels confusing or stalled.

Please check any that feel familiar to you:

Please check any that feel familiar to you:

I feel like I am not being fully heard

I say one thing, but it seems to be understood differently

I feel like I keep getting put into boxes that do not quite fit

I am told things look “normal,” but something still feels wrong

I leave appointments feeling confused, dismissed, or unsure

I struggle to explain everything clearly in the time given

I feel like there is more going on than what is being addressed

I am coordinating care for myself or someone else and feel overwhelmed

I am not sure what the next step should be

Other (optional)

Optional notes (if anything stands out):

This is the most important part.

In your own words, please share:

What has been happening with your health or care — and where does it feel confusing, stalled, or overwhelming right now?

You do not need to explain everything perfectly.
We are listening for patterns, gaps, and pressure points — not judging accuracy.

What has been happening with your health or care?

How long has this situation been affecting you?

Less than 3 months

3–12 months

1–3 years

More than 3 years

About how many healthcare providers have been involved?

1–2

3–5

6 or more

Unsure

How many different clinics, hospitals, or health systems?

3 or more

Unsure

How would you describe things right now?

Stable

Slowly changing

Worsening

Fluctuating or unpredictable

Do you already have medical records available?

Yes — a small amount

Yes — a lot

Not yet

Unsure

Would you like a provider-ready summary packet you can share with your medical team?

Yes

Unsure

Are you comfortable with Avora using AI tools to help organize information and surface additional possibilities to discuss with your medical providers?

Yes

I have questions first

HOW AVORA HELPS

Avora helps people make sense of complex or stalled healthcare situations.

We focus on:

organizing your story, records, and test results into a clear timeline
highlighting symptoms, patterns, and gaps that may be getting missed
preparing you for clearer conversations with your providers
(optional) creating a provider-ready summary packet, including a one-page snapshot of your main concerns, timeline, symptoms, and key questions

We do not diagnose, prescribe, or replace medical care.
If we are not the right fit, we will tell you honestly.

WHAT HAPPENS AFTER THIS

After reviewing your intake, we may recommend one of the following — or none at all:

One-Time Clarity Review
A focused review to organize your situation and identify next steps.

Deeper Case Review
A deeper review for long timelines, complex histories, or multiple providers and records, including AI-assisted screening to surface additional medical possibilities and rule-out questions for your medical providers to consider, plus a provider-ready summary packet you can share with them.

Navigation Support
Ongoing support for a period of time to help appointments and care stay on track, including preparation before each visit and updated summary packets after each visit.

We will explain our recommendation clearly and without pressure.

Full Name

Phone number (optional)

Do you prefer

Call

Text

Either

Thank you for sharing this.

We will review your information carefully and follow up if Avora feels like a good fit.

Avora Intake

ABOUT AVORA™

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