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PATIENT DETAILS FORM ::    
First Name:   *
Family / Last Name:   *
Gender:   Male Female
Date Of Birth:  
Height:  
Weight:  
Nationality:  
CONTACT INFORMATION ::    
Home Address:  
City / Town:  
Country:  
Zip / Post Code:  
E-Mail:   *
Tel (Home):  
Mobile:  
Travel Companions Name:  
BOOKING DETAILS ::    

Request Date Of Treatment:

  
Arrive Phuket:  

Depart Phuket:

  

PATIENTS MEDICAL CONDITION ::
Heart Disease : Not Known None Yes ( Please specify )
Diabetes : Not Known None Yes ( Please specify )
Hypertension : Not Known None Yes ( Please specify )
Deep Vein Thrombosis : Not Known None Yes ( Please specify )
Cardiovascular Accidents : Not Known None Yes ( Please specify )
Asthma : Not Known None Yes ( Please specify )
Bleeding Tendency : Not Known None Yes ( Please specify )
Hyperthyroidism : Not Known None Yes ( Please specify )
Hypothyroidism : Not Known None Yes ( Please specify )
Adrenal Insufficiency : Not Known None Yes ( Please specify )
Hepatitis : Not Known None Yes ( Please specify )
HIV : Not Known None Yes ( Please specify )
Kelpid Scarring : Not Known None Yes ( Please specify )
Cancer : Not Known None Yes ( Please specify )
Major Operation : Not Known None Yes ( Please specify )
Other : Not Known None Yes ( Please specify )
Underlying Disease : Not Known None Yes ( Please specify )
Drug Allergies : Not Known None Yes ( Please specify )
Food Allergies : Not Known None Yes ( Please specify )
Current Medications and Dosage : Not Known None Yes ( Please specify )
Current vitamins, food / nutritional supplements : Not Known None Yes ( Please specify )
Have you ever been treated for depression : Not Known None Yes ( Please specify )

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Patong Dental Clinic
78/16 Thaweewong Road Patong Phuket 83150
Tel: +66 (0) 822814155
E-mail: info@patongdentalclinic.com    Website: www.patongdentalclinic.com

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