Pre-Consultation and Prescription form
Please complete the following form. This information is essential for us to create your Por Tor 33 prescription form. Please complete all fields to the best of your ability. If you are unsure about anything, you can simply leave it blank and discuss it with the doctor during your consultation.
Date / วันที่
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Day
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Month
Year
Date
Please Select the store you are at or intent to visit
*
Please Select
Wonderland - Soi Sukhumvit 5, Khwaeng Khlong Toei Nuea, Khet Watthana, Bangkok 10110.
Wonderland Clinic 93 (Unit B), Sukhumvit Soi 5, Sukhumvit Rd, Khlong Toei Nuea, Wattana, Bangkok 10110
Cloud Nine Asoke - 221 Sukhumvit Rd, Khlong Toei Nuea, Watthana, Bangkok 10110.
Cloud Nine Surawong - 178 Surawong Rd, Si Phraya, Bang Rak, Bangkok 10500.
Kush House - 1 Soi Sukhumvit 22, Klongton, Khlong Toei, Bangkok 10110.
Mary Jane Nana - 106 Sukhumvit Rd, Khwaeng Khlong Toei, Khlong Toei, Bangkok 10110.
Mary Jane Patpong - 048 Patpong 2 Alley, Surawong Rd, Suriya Wong, Bang Rak, Bangkok 10500.
Lucky Lukes Tiki Joint - 52/4 Sukhumvit Rd, Khlong Toei Nuea, Watthana, Bangkok 10110
Juicy Buds Phuket - 198, 4 Thawewong Rd, Pa Tong, Kathu District, Phuket 83150
OG Surplus
Name
*
First Name
Last Name
Gender
*
Please Select
Male
Female
N/A
Age
*
Passport/ ID number
*
Nationality
*
Please Select
Japan
China
UAE
UK
USA
India
Taiwan
France
Germany
Singapore
Malaysia
Philippines
Dubai
Russia
Thailand
Australia
Pakistan
Korea
Switzerland
Norway
Spain
Canada
Italy
Myanmar
Afghanistan
Albania
Algeria
Andorra
Angola
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Central African Republic
Chad
Chile
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Israel
Ivory Coast
Jamaica
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Maldives
Mali
Malta
Mauritania
Mauritius
Mexico
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia
Oman
Palau
Panama
Papua New Guinea
Paraguay
Peru
Poland
Portugal
Qatar
Romania
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Slovakia
Slovenia
Solomon Islands
South Africa
South Sudan
Sri Lanka
Sudan
Suriname
Sweden
Syria
Tajikistan
Tanzania
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Emergency Contact info
Someone we can contact in case of an emergency
Contact's Name
*
Contact's Phone Number
*
Your Contact information
Contact information is required to complete your registration
Do you use WhatsApp or Line? If so, please provide your ID or phone number
How do you prefer to be contacted
Email
Phone
Whatsapp
LINE
Do you currently reside in Thailand?
Yes
No
Generally, how often do you visit Bangkok in a year
Lifestyle information
To help us understand you a bit more
Your weight
Your height
Do you smoke Cigarettes, Cannabis ?
*
Yes
No
If yes, how are you a light or heavy smoker?
How many joints and or cigarettes per week
Do you Drink Alcohol?
*
Yes
No
If yes, how many units a week?
Are you pregnant or breastfeeding
*
No
Medical History
More information about your medical history
Have you had any surgeries
yes
no
If yes, please give brief information
Are you currently on any medication
*
yes
no
If yes, please give brief information
Do you have any allergies?
Yes
No
If you answered “Yes” above, please specify your allergies here:
Are you receiving any medical treatment in Thailand
yes
no
Patient Signature
*
Please submit your form
The next page is for the doctor to complete at your consultation
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Controlled Herbal Prescription Form (Cannabis)
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ข้าพเจ้า
Please Select
สมัชญา เครือเนตร
กนิษฐา กุลทองบุณยพร
ณัฐภัทร นุชแนวดีศรี
จิรายุทธ แย้มเย็น
พลอยไพลิน คงทน
นายปฏิพัทธ์ พรมแก้ว
ใบอนุญาตเลขที่
ใบอนุญาตเลขที่
ใบอนุญาตเลขที่
ใบอนุญาตเลขที่
ใบอนุญาตเลขที่
ใบอนุญาตเลขที่
ซึ่งเป็น
ผู้ประกอบวิชาชีพเวชกรรม
แพทย์แผนไทย
แพทย์แผนไทยประยุกต์
ทันตกรรม
เภสัชกรรม
ผู้ประกอบโรคศิลปะ สาขาการแพทย์แผนจีน
หมอพื้นบ้าน
ที่อยู่
พบว่ามีโรคหรืออาการ
Please Select
นอนไม่หลับ
เบื่ออาหาร
ไมเกรน(ลมปะกัง)
พาร์กินสัน(สันนิบาตลูกนก)
กลุ่มอาการ/โรคปวดเรื้อรังจากมะเร็ง
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-
-
-
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Dose per Day (in grams)
How long to use (number of days)
Total doses required (grams)
Doctors Notes:
Photo of Patient
Submit
Should be Empty: