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REQUEST TO SCHEDULE SURGERY
WITH DR.CHARTCHAI

I am ready to proceed with surgery by Dr. Chartchai.

Note: All information is required.

 

   
 
For all non-surgical or
non-medical requests,
please send an email

 

I have a reference number :
I have a hospital number :
from (Hospital)
I have consulted in person with Dr. Chartchai. My consultation was on
I have received an email advisory and cost quotation from Dr. Chartchai.
I live in Bangkok. My preferred surgery date is
Alternative date is
I do not live in Bangkok. I will be traveling from (City) (Country) I plan to arrive in Bangkok on
(Day) (Month) (Year)
Email address:
Confirm email address:
 
Your message:

 

 

 

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