Pinkerbell Telemedicine

PINKERBELL CLINIC TELEMEDICINE

Easier to make Your private appointment with Us
Nama / Name*
Have you previously attended our facility / Pernah kah anda datang ke Pinkerbell Clinic ?*

Ya / YesTidak / No
Jenis Kelamin / Gender*
Telepon / Phone Number*

Kode Area / Area CodeNo. Telephone / Phone Number
Tanggal Lahir / Date of Birth*

DayMonthYear
Alamat / Address*

Alamat / Street Address

Kota / CityProvinsi / Province

Kode Pos / Zip Code
E-mail*
myname@pinkerbellclinic.com
Riwayat kondisi penyakit tertentu / Any kind of Health condition? ( Pilih bisa lebih dari satu )

Tidak AdaAlergiTekanan darah tinggi / HipertensiGula darah tinggi / Diabetes MelitusMaag lambung /GastritisPusing berputar / VertigoOther
Riwayat Penggunaan obat tertentu? ( Tuliskan nama obat dan dosis penggunaan )
Pilih jenis Appointment yang diinginkan / Select which appointment type(s) you require*

Teleconsultation ( 15 Menit )Immune Acceleration Injection IV TherapyHollywood Infuse IV TherapyPinkerbell Fairy Laser Glow ( PFLG )Pinkerbell Pulse Light Therapy ( PPLT )Pinkerbell Laser Sxarway FC02Vampire Muggle Blood Therapy ( VMBT )Package Promo Facial 4x for ALL TYPE ( 2.5 bulan Valid)Promo Buy 2 get 2 Package Immuno Acceleration (IV Therapy)
Name

First NameLast Name
Appointment Type
Teleconsultation Price
Immuni Acceleration Price
Promo Paket Immuni Acceleration Price
Hollywood Infusion Price
Pinkerbell Fairy Laser Glow
Pinkerbell Pulse Light therapy
Pinkerbell Sxarway
Vampire Muggle Blood Therapy
Paket Facial 4x
Pilih Penjadwalan / Choose Your Appointment Schedule*
TOTAL PEMESANAN
total hidden
Note: Mohon di isi dengan lengkap. Dan lanjutkan pada tahapan selanjutnya
Should be Empty:

PINKERBELL CLINIC TELEMEDICINE

Appointment Type