해외환자유치예약시스템
Sender
boltname boltArea
boltE-mail boltTel
 
Patient
boltName boltNationality
boltDate of birth boltAge/sex
boltArrival scheduled date and time boltInformation of fight
(Airlines, Flight No., Arrival time)
boltKinds of treatment desired
boltDisease or openration history
boltAllergy


(Write detailed as possible and If there is nothing, please write 'nothing'.)

boltPresent status
boltCan you send data for Xray, MRI, CT-scan, etc.? Y N
boltThings hospital needs to check about patients except the above.
(If there is nothing, please write 'nothing'.)
boltThe necessity of interpreting
(Please inform us of the language partient or guardian speak)
boltAccopany with guardian

(If accompanied, how many guardians will be.)

boltPatient contact name relation oneself
Tel
E-mail
address
fax
boltGuardian contact name relation oneself
Tel
E-mail
address
fax
boltContact for emergency name relation oneself
Tel
E-mail

address
fax
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