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Preferred Appointment
Date*
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Time*

: Hours

Minutes

AM/PM
Need more option
- Yes
Date (option 2)
MM slash DD slash YYYY
Time

: Hours

Minutes

AM/PM
Note: This schedule is based on normal doctor clinic hours. As there may be changes to the schedule from time to time, please wait for our representative to confirm your appointment timing.
Medical Concern or Request*
File
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Accepted file types: zip, pdf, rar, jpg, jpeg, gif, png, Max. file size: 5 MB, Max. files: 3.
Patient Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
- Prefer Not to Answer
Country of Residence*
Nationality*
Email*
Enter Email Confirm Email
Primary Phone Number*
Visited Vejthani before?
- Yes
Hospital Number (HN)
Do you need an interpreter?
- Yes
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