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Appointment Request

필수마크 Required

Request an Appointment

CUH Medical Record No.

Name

Gender

Male
Female

Date of birth

Alien Registration No.(If applicable)

-

Passport No.

Passport/Registration Expiration Date

Nationality

Language

Contact No. (In Korea)

Phone Number

E-mail:

Emergency Contact

Contact Name & Relationship to Patient

Phone

Address in Korea

Permanent Address

Private Insurance

Yes
No

Symptoms & Medical Services Required

Available Dates & Comments

Required

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