PATIENT REGISTRATION | Lowlands Clinic

Full name (Title, First Name, Last Name)

Age:

Nationality:

Thai ID/Passport Number

Upload ID/Passport photo

Phone

Email

Line ID

Temporary Address/Hotel

Are you currently taking any medication?

YES

NO

If YES, please list them here:

Are you currently pregnant or breast-feeding?

YES

NO

I confirm that the information provided above is true and accurate to the best of my knowledge.

I consent to a medical evaluation and prescription under Thai Traditional Medicine guidelines.

I understand that cannabis is prescribed only for approved medical conditions under Thai law.

Date

Day

Month

Year

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Patient registration form