Appointment Booking - Dr. Pongsak Clinic

Full Name *

Email *

Phone Number *

Age *

Gender *

Male Female Other

Type of Treatment *

Preferred Appointment Date *

Preferred Time *

Available Booked

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

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File 3 File 3

File 4 File 4

File 5 File 5

Upload Medical Documents (if any) (สูงสุด 5 ไฟล์ 5MB/ไฟล์ - PDF, JPG, PNG)

Additional Notes *

Consultation Fee

A consultation fee of 1,000 THB applies, which 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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