Bestil tid — Dr. Pongsak Klinik

Patientinformation

Title *

First name *

Last name *

Angiv venligst mindst én: e-mail, telefon eller WhatsApp

E-mail *

Mobil

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

Aftalepræferencer

Behandlingstype *

Number of people

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

Foretrukken aftaledato *

Foretrukken tid *

Ledig Booket

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

Medicinsk information

Sygehistorie

Allergier

Nuværende medicin

Tidligere operationer

Helbredstilstande

Upload medicinske dokumenter (hvis nogen)

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Fil 2 Fil 2

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Upload medicinske dokumenter (hvis nogen) (Max 5 filer, 5MB hver — PDF, JPG, PNG)

Yderligere bemærkninger

Jeg anerkender og accepterer at betale konsultationsgebyret på 1.000 THB *