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Untitled Document
Consultation Form
*Patient’s name
*Gender Male / Female
*Data of Birth (Day ? Month - Year)
*Nationality
*Language
*Passport Number
*Korean National
Health Insurance
Yes / No
*Contact Number
(in Korea)
Telephone number - -
Mobile number - -
E-mail @
Fax Number - -
Emergency Contact Name
Relation to the patient
Telephone number - -
*Appointment
Information
Type of registration First / Revisit
Request Date (Date: day ? Month - Year)
Referring M.D Hospital’s name
Doctor’s name @
Telephone number - -
*Symptoms
Contents
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+82-31-231-7300

288, Jang Dari-ro, Paldal-qu, Suwon 442-832, Korea
Phone: +82-31-231-7300 Fax: +82-31-231-7400
Hospital name : Shesmedi Obstetrics and gynecology/Pediatrics
Representatives : Lee Kiho Business Registration Number : 124-96-12917
copyright 2014. shesmedi HOSPITAL. all rights reserved.