Appointment Booking - Dr. Pongsak Clinic

Patient Information

Title *

First name *

Last name *

Please provide at least one: email, phone, or WhatsApp

Email

Mobile

LINE ID

Additional information (optional — speeds up your visit) Optional

Fill in these optional details to skip paperwork at the counter. We use this information to pre-create your patient profile so we can serve you faster on arrival.

ID document

Thai national ID Passport Skip (provide at clinic)

Date of birth

Use Christian Era year (e.g. 1985)

Address

Appointment Preferences

Consultation purpose *

Preferred Appointment Date *

Preferred Time *

Available Booked

13:00 - 13:30 13:30 - 14:00 14:00 - 14:30 14:30 - 15:00 15:00 - 15:30 15:30 - 16:00 16:00 - 16:30

Medical Information

Medical History

Allergies

Current Medications

Previous Surgeries

Health Conditions

Upload Medical Documents (if any)

File 1 File 1

File 2 File 2

File 3 File 3

File 4 File 4

File 5 File 5

Upload Medical Documents (if any) (Max 5 files, 5MB each — PDF, JPG, PNG)

Additional Notes

Consultation Fee

A consultation fee of 1,000 THB is prepaid via a payment link sent to your email. This fee is non-refundable.

I acknowledge and agree to pay the 1,000 THB consultation fee *