Patient name(please list name as it appears on passport)
name
*
Date of Birth
*
Patient's gender
*
Male
Female
Nationality
*
Domicile
*
in Korea
Overseas
Mobile Phone
Email
*
Medical Dept
*
- Select Medical Field -
General Hospital
Plastic Surgery
Dermatology
Dentistry
Oriental Medicine
Health Screening
Spine/Joint
Women's Clinic
Hair loss
Ophthalmology
Otorhinolaryngology
Neurosurgery
Others
Medical Insititution
*
Diagnosis/symptoms
*
Appointment date requested
*
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