Medical register

Date of visit *
RadDatePicker
RadDatePicker
Open the calendar popup.
Full Name *
Date of birth *
RadDatePicker
RadDatePicker
Open the calendar popup.
Phone *
Address *
Time to visit *
Disease symptoms *
Gender *
Health Insurance *
Expert examination*
Has the patient ever been examined at a hospital? *

* Please complete all information

Location: 383 Lan Be, Lam Son, Le Chan, Hai Phong, Vietnam
Email: haiphongeyehospital@gmail.com
Hotline: 0934.376.972
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