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Patient's Hospital ID number
Certificate Issue Number
No. of pages of This Document
Patient's Name
(Family name/Given name/Middle name)
Gender
Birthday (m,d,y) ex) 12 / 25 /1977

Nationality (Homeland)
Passport Number
Languages (Spoken & Understood)
Address in Korea Postal code :
Province(Do) :
City(Si) :
District(Gu) :
Area(Dong) :
Apartment / Building Number :

Permanent Address Permanent Address :
Street :
City :
State / Province / Territory :
Country :
Postal coe / Zip code :

Telephone Number (In Korea) Home :
Office / Fax / E-mail :

Emergency Contact Name and Title :
Relationship to the patient :
Telephone Number :

Referring M.D. Print or type Name & Title :
Office Telephone Number :
Mobile phone Number :

Medical services required Medical doctors required

Remarks

Attending Physician
(please print or type / Name and title)
Attending Physician's signature and seal
Date (mm/dd/yyyy) ex) 12 / 25 /1977

Payment Method
Cash Visa Master card
  Other :

This service is provided to foreigners who are with or without Korean government health insurance.
INTERNATIONAL HEALTHCARE SERVICE
PHONE :(INT82-2)2072-2890,0505
MOBILE :(INT82)11-9150-2890(24 HRS and Emergency call also)
FAX :(INT82-2)2072-0785

  
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