Request Telemed Service – คลินิกเวชกรรม สวท

Basic Information

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UUID

Title(Required)

Name(Required)

Surname(Required)

Mobile Number(Required)

0 of 10 max characters

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Sex

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pmseu

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ID Card Number/Passport(Required)

DOB(Required)

Age(Required)

Personal Information

Weight(Required)

0 of 3 max characters

Height(Required)

0 of 3 max characters

Education(Required)

occupation(Required)

marital status(Required)

nationality(Required)

Address for pills delivery

region(Required)

current address(Required)

Subdistrict(Required)

District(Required)

province(Required)

zip code(Required)

0 of 5 max characters

Emergency Contact

contact name(Required)

Contact's last name(Required)

Mobile Number(Required)

0 of 10 max characters

Medical Information

Do you have a history of drug allergies?(Required)

a history of drug allergies(Required)

health history and regular medications(Required)

Gravidity (the number of times you are or have been pregnant regardless of outcome)(Required)

having children included(Required)

being a woman (person)(Required)

male (person)(Required)

method of childbirth(Required)

How many times have you had an abortion?(Required)

How is it a miscarriage?(Required)

What is the gestational age (weeks)?(Required)

More than 12 weeks (please specify gestational age)(Required)

Cause of pregnancy(Required)

Other reasons, please specify.(Required)

The reason for receiving abortion service(Required)

Other reasons, please specify.(Required)