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Payment Detail

Payment TypePay for Treatments/ Operation/ Medication and Supplies/ Deposit
Detail-
ByCredit Card
Amount0 THB

Contact Information

Firstname - Lastname -
ID Card or Passport No.
The address can be contacted
Country of residence
Zip Code/ Postal Code
Email
Phone Number

Patient Information

Firstname - Lastname -
Gender
Nationality
Date of Birth
Patient Hospital Number
Room Number
Treatment / Appointment date

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