Reservation from KITJAWET CLINIC
Please put your information from True !!
Your Name *
First Name and Last Name
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Your Gender *
Male or Femel
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Your address / residence or hotel in Bangkok *
Example : Bangruk hotel 101 Wongsawang11 Bangsue 10800
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Your Telephone/Mobile Phone *
+66899665XXX
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Your Nationality *
Thailand,United Kingdom,Russia,Affrigan
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Your indications for treatment
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Reservation date for consultation *
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Reservation time *
(for example 9.30 AM)
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Note
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