Chaum
Medical Checkup
Anti-Aging
Beauty & Wellness
Bio Technology
Community
Reservation
Personal information collection and usage agreement 1. Required Personal Information Nationality/ Name/ Gender/ Date of Birth/ E-mail Address/Contact Number/ Interest/ Object of Consultation 2. Purpose of Collection and Use To book an appointment and conduct an online consultation for a medical examination. 3. Use and Retention Period of Personal Information : Three months To book an appointment and conduct an online consultation for a medical examination. 4. Refusal or Consent to Collection and Use of Personal Information All patients have the right to refuse to give their personal information. Please be aware that it shall not be possible to have an online consultation service and book an appointment if you rejects to give your personal data.
I agree
I don't agree.
Yes
No
English
Russian
Chinese
Passport or Alien Register No
Given Name
Surname
Male
Female
Date of Birth
Nationality
Country of Residence
Address in Korea
Email
Phone No
Health Checkup Programs*
Basic
Cancer
Whole Body
Noble
Additional Electives
Brain
Immunity
Heart
Digestive
Anti-Aging Plus
Preferred Date
Date and findings from your past check-up
Medical Conditions
Medications
Previous Surgeries & Dates
Allergies?
Risk for Dental Injury?
* Radiographic examinations cannot be completed during pregnancy
Date of Last Menstruation
* Menstruation may interfere with the gynecological exam and urinalysis.
Date of arrival in Korea
Departure date from Korea
Symptoms/ Discomforts
Comments