Patient Prescription form (Eng)

  • 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
     - -

  • Emergency Contact info

    Someone we can contact in case of an emergency

  • Your Contact information

    Contact information is required to complete your registration
  • How do you prefer to be contacted
  • Do you currently reside in Thailand?

  • Lifestyle information

    To help us understand you a bit more
  • Do you smoke Cigarettes, Cannabis ?*
  • Do you Drink Alcohol?*

  • Medical History

    More information about your medical history
  • Have you had any surgeries
  • Are you currently on any medication*
  • Do you have any allergies?
  • Are you receiving any medical treatment in Thailand

  • Please submit your form

    The next page is for the doctor to complete at your consultation

  • NEXT PAGE IS FOR YOUR DOCTOR ONLY

    Controlled Herbal Prescription Form (Cannabis)
  • ซึ่งเป็น
  • Should be Empty: