- Basic information -
photo upload
Family name :
Name :
Date of birth yy/mm/dd :
Sex : m / f
Nationality :
Patient address :
Tel :
Phone :
E-mail :
SNS :
State/province :
Address in Korea :
List preferred contact method :
Preferred time :
- Hospital booking -
Hospital dept.
Medical institution
Diagnosis / symptoms
Appointment date requested
Taking medications
Medical history
Comments

This form is required during the booking process for consulation at the hospital.

Please fill in the necessary information honestly.