Pre-Fill Patient Entry Form
Please fill in your contact details. (ex. email and or phone number)
Reason for visit?
Lab test results
Please inform us of any allergies or regular medication you are taking:
Insurance policy number?
If you selected yes on the previous question please fill in this question
~You certify by signing this form that you agree to pay a clinic fee of 200 or baht to support the operation of Medconsult Clinic. ~You certify by signing this form that you agree to pay a minimal consultation fee of 600 bath if you see the Doctor.
Should be Empty: