Appointment Booking - Dr. Pongsak Clinic

Full Name *

Please provide at least one: email, phone, or WhatsApp

Email

Mobile

Gender *

Male Female Other

Type of Treatment *

Preferred Appointment Date *

Preferred Time *

Available Booked

10:00 - 10:30 13:00 - 13:30 13:30 - 14:00 14:00 - 14:30 14:30 - 15:00 15:00 - 15:30 15:30 - 16:00 16:00 - 16:30 16:30 - 17:00

Medical History *

Allergies *

Current Medications *

Previous Surgeries *

Health Conditions *

Preferred Contact Method *

Phone Call Email LINE WhatsApp

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Upload Medical Documents (if any) (Max 5 files, 5MB each — PDF, JPG, PNG)

Additional Notes *

Consultation Fee

A consultation fee of 1,000 THB is prepaid via a payment link sent to your email, and will be credited toward your surgery should you proceed

I acknowledge and agree to pay the 1,000 THB consultation fee *

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