Nurse Consultation And Service
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Application Form For New Client
No. 10AE1, St. 570, Sangkat Boeung Kok Ⅱ,Khan Toul Kork, Phnom Penh, Cambodia.
Tel: 017 665 473
Contact about problems, questions or comments with the following form. It may take times to reply for the mailing form. You may contact by phone during the business hour.
(Please write the occupation, hobby, handedness, diagnosis, medical history, medication,
hospital and primary care) Remarks.
3-Problems in daily
Under the influence of the above symptoms, please write in your daily life movement that can not do
Please tell us how painful is it? number 5 is very painful
5-Site of the pain:
Please tell us the painful area:
Monday, this week
Tuesday, this week
Wednesday, this week
Thursday, this week
Friday, this week
Saturday, this week
Monday, next week
Tuesday, next week
Wednesday, next week
Thursday, next week
Friday, next week
Saturday, next week
6-When you want to come?
NGO JAPAN MEDICAL DEVELOPMENT ORGANIZATION
Today: Apr 25, 2017
Kitahara Neurosurgical Institute Phnom Pehn, Kitahara Japan Clinic
Address: No.10AE1, St. 570, Sangkat Boeung Kok 2,
Khan Toul Kork, Phnom Penh