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