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诊疗预约

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诊疗预约 > 预约诊疗

预约诊疗

Patient’s Hospital ID Number Only for revisit patient
Patient Name (Family Name/Given Name/Middle Name)
Gender  Male  Female
Birthday(D.M.Y) ex) 21.10.2010
Alien Registration Card Number
Name of Health Insurance
Nationality
Passport Number
Address in Korea
Permanent Address
Contact Number (In Korea) Telephone Number
Mobile Number
E-mail
Fax Number
Emergency Contact Name
Relationship to the Patient
Telephone Number
Request Date
Sign & Symptoms
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