True Thai Medication Form
These questions are asked for your own safety. The information given will be treated as private and confidential, and will not be revealed to any third party without your prior authorisation in writing.
Name - Surname *
Address *
Contact number *
Email address
Do you suffer from any of the following Medical Conditions?
Please tick if yes.
Please state the particular area if needed to be treated.
I confirm (to the best of my knowledge) that the answers I have given are correct, and that I have not withheld any information that may relevant to my treatment. I confirm that Nongnuch Thongkhong (True Thai Edinburgh) will not be held responsible for any adverse reaction caused by withholding information.
Signature & Date *
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