INFORMATION FOR PHYSICIAN'S OFFICE
The following information is required by physician practice offices in order to schedule an appointment:
Name
Gender
::: Select Gender :::
Male
Female
Nationality
::: Select Nationality :::
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia-Hertzagovina
Botswana
Brazil
British Virgin Islands
Brunei Darussalm
Bulgaria
Burkina Faso
Burma (Myanmar)
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros & Mayotte
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji Islands
Finland
French Guiana
French Polynesia
Gabonese Republic
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada/Carricou
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakstan
Kenya
Kiribati, Gilbert Islands
Kuwait
Kyrgyz Republic
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Metropolitan France
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
N. Mariana Islands
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue Island
North Korea
Northern Ireland
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion (France)
Romania
Russia
Rwanda
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
St Helena
St Kitts and Nevis
St Lucia
St Pierre & Miquelon
St Vincent/Grenadines
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togolese Republic
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos
Tuvalu, Ellice Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Western Samoa
Yemen
Zaire
Zambia
Zimbabwe
Date of birth
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dd
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mm
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2008
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Contact number
Home :
Mobile :
Address
Email
Subject
To make an appointment for a treatment
1) Major complaints or symptoms
2) For how long have you had that symptom?
3) Do you have MRI or CT or X-ray films? If yes, please bring them with you.
4) Do you prefer any doctor in Jaseng you want to see?
5) Time & date of visit
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dd
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mm
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yyyy
To make an inquiry
Any kind of your inquiry will be answered with courtesy.
How did you get to know about Jaseng hospital?
For further information, please call at 02-3218-2167 or 02-3218-2105. English or Japanese speaking assistants will be attending.
Copyright@2006 Jaseng Hospital of Oriental Medicine All right Reserved.