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

Type of Treatment *

Number of people

฿1,000 consultation fee per person — if several people attend on one booking, the fee is multiplied accordingly.

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

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