Medical Intake Form
*Please provide all diagnostics and existing medical records (if any) done within the past year.*

Kindly please take your time to complete this form. This form's purpose is to let our doctors better understand your condition(s) to evaluate your treatment. We estimate that it will take about 15 minutes of your time. The contents of this form will be kept strictly confidential and will only be shared with your consent and in accordance with our data protection policy.

Once we have received your information, we will then pass this information to our medical specialists for evaluation. Our clinic is located in Bangkok, Thailand where all our treatments take place, where patients from all over the world come over to receive our professional medical services and care.

Thank you for your time and we look forward to seeing you here at the Good Life Center.
Email address *
Patient's Personal Particulars
Full Name *
Your answer
Gender *
Phone Number ( Include International Code) *
Your answer
Mailing Address *
Your answer
Country of Residence *
Age *
Your answer
Height *
Your answer
Weight *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Blood type *
Health Condition(s) that you will like to treat
Your answer
Convenient Date for consultation *
MM
/
DD
/
YYYY
Convenient Time for consultation *
Emergency Contact Details
Full Name *
Your answer
Phone Number (Including International Code) *
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy