{"id":731,"date":"2024-11-18T06:15:28","date_gmt":"2024-11-18T06:15:28","guid":{"rendered":"https:\/\/dymclinic.com\/en\/?page_id=731"},"modified":"2025-04-21T07:31:37","modified_gmt":"2025-04-21T07:31:37","slug":"registration-form-for-children","status":"publish","type":"page","link":"https:\/\/dymclinic.com\/en\/registration-form-for-children\/","title":{"rendered":"Registration for children"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f752-o1\" lang=\"ja\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/731#wpcf7-f752-o1\" method=\"post\" class=\"wpcf7-form init\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"752\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"ja\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f752-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Sex<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap sex\"><select name=\"sex\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please select\">Please select<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><option value=\"Others\">Others<\/option><\/select><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Name(English)<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput namebox\">\n    <span class=\"wpcf7-form-control-wrap familyname\"><input type=\"text\" name=\"familyname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Family name\" \/><\/span><span class=\"wpcf7-form-control-wrap firstname\"><input type=\"text\" name=\"firstname\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First name\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Date of Birth<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput birthday_box\">\n    <span class=\"wpcf7-form-control-wrap birth_year\"><select name=\"birth_year\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Year\">Year<\/option><option value=\"2004\">2004<\/option><option value=\"2005\">2005<\/option><option value=\"2006\">2006<\/option><option value=\"2007\">2007<\/option><option value=\"2008\">2008<\/option><option value=\"2009\">2009<\/option><option value=\"2010\">2010<\/option><option value=\"2011\">2011<\/option><option value=\"2012\">2012<\/option><option value=\"2013\">2013<\/option><option value=\"2014\">2014<\/option><option value=\"2015\">2015<\/option><option value=\"2016\">2016<\/option><option value=\"2017\">2017<\/option><option value=\"2018\">2018<\/option><option value=\"2019\">2019<\/option><option value=\"2020\">2020<\/option><option value=\"2021\">2021<\/option><option value=\"2022\">2022<\/option><option value=\"2023\">2023<\/option><option value=\"2024\">2024<\/option><option value=\"2025\">2025<\/option><\/select><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap birth_month\"><select name=\"birth_month\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Month\">Month<\/option><option value=\"January\">January<\/option><option value=\"February\">February<\/option><option value=\"March\">March<\/option><option value=\"April\">April<\/option><option value=\"May\">May<\/option><option value=\"June\">June<\/option><option value=\"July\">July<\/option><option value=\"August\">August<\/option><option value=\"September\">September<\/option><option value=\"October\">October<\/option><option value=\"November\">November<\/option><option value=\"December\">December<\/option><\/select><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap birth_day\"><select name=\"birth_day\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Day\">Day<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><option value=\"13\">13<\/option><option value=\"14\">14<\/option><option value=\"15\">15<\/option><option value=\"16\">16<\/option><option value=\"17\">17<\/option><option value=\"18\">18<\/option><option value=\"19\">19<\/option><option value=\"20\">20<\/option><option value=\"21\">21<\/option><option value=\"22\">22<\/option><option value=\"23\">23<\/option><option value=\"24\">24<\/option><option value=\"25\">25<\/option><option value=\"26\">26<\/option><option value=\"27\">27<\/option><option value=\"28\">28<\/option><option value=\"29\">29<\/option><option value=\"30\">30<\/option><option value=\"31\">31<\/option><\/select><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Phone Number<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput tel_box\">\n    <span class=\"wpcf7-form-control-wrap tel_country\"><select name=\"tel_country\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"+66(Thailand)\">+66(Thailand)<\/option><option value=\"+81(Japan)\">+81(Japan)<\/option><option value=\"+1(USA)\">+1(USA)<\/option><option value=\"+1(Canada)\">+1(Canada)<\/option><option value=\"+44(UK)\">+44(UK)<\/option><option value=\"+49(Germany)\">+49(Germany)<\/option><option value=\"+33(France)\">+33(France)<\/option><option value=\"+39(Italy)\">+39(Italy)<\/option><option value=\"+86(China)\">+86(China)<\/option><option value=\"+82(Korea)\">+82(Korea)<\/option><option value=\"+61(Australia)\">+61(Australia)<\/option><option value=\"+91(India)\">+91(India)<\/option><option value=\"+63(Philippines)\">+63(Philippines)<\/option><option value=\"+62(Indonesia)\">+62(Indonesia)<\/option><option value=\"+60(Malaysia)\">+60(Malaysia)<\/option><option value=\"+65(Singapore)\">+65(Singapore)<\/option><option value=\"+84(Vietnam)\">+84(Vietnam)<\/option><option value=\"+7(Russia)\">+7(Russia)<\/option><option value=\"+52( Mexico)\">+52( Mexico)<\/option><option value=\"+55(Brazil)\">+55(Brazil)<\/option><option value=\"+54(Argentina)\">+54(Argentina)<\/option><option value=\"+27(South Africa)\">+27(South Africa)<\/option><option value=\"+966(Saudi Arabia)\">+966(Saudi Arabia)<\/option><option value=\"+90(Turkey)\">+90(Turkey)<\/option><option value=\"+974(Qatar)\">+974(Qatar)<\/option><\/select><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap tel\"><input type=\"text\" name=\"tel\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"02-107-1039\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Email<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap email\"><input type=\"email\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"contact@dym.co.th\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Insurance<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap insurance\"><select name=\"insurance\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please select\">Please select<\/option><option value=\"Bangkok Life\">Bangkok Life<\/option><option value=\"Mitsui Thai\">Mitsui Thai<\/option><option value=\"Ocean Life\">Ocean Life<\/option><option value=\"MED SURE\">MED SURE<\/option><option value=\"AIA\">AIA<\/option><option value=\"MuangThai Insurance\">MuangThai Insurance<\/option><option value=\"Tokio Marine Thailand\">Tokio Marine Thailand<\/option><option value=\"Thai Life\">Thai Life<\/option><option value=\"Others\">Others<\/option><\/select><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Address<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap address\"><input type=\"text\" name=\"address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Emergency Contact<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput tel_box\">\n    <span class=\"wpcf7-form-control-wrap tel_country-kinkyu\"><select name=\"tel_country-kinkyu\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"+66(Thailand)\">+66(Thailand)<\/option><option value=\"+81(Japan)\">+81(Japan)<\/option><option value=\"+1(USA)\">+1(USA)<\/option><option value=\"+1(Canada)\">+1(Canada)<\/option><option value=\"+44(UK)\">+44(UK)<\/option><option value=\"+49(Germany)\">+49(Germany)<\/option><option value=\"+33(France)\">+33(France)<\/option><option value=\"+39(Italy)\">+39(Italy)<\/option><option value=\"+86(China)\">+86(China)<\/option><option value=\"+82(Korea)\">+82(Korea)<\/option><option value=\"+61(Australia)\">+61(Australia)<\/option><option value=\"+91(India)\">+91(India)<\/option><option value=\"+63(Philippines)\">+63(Philippines)<\/option><option value=\"+62(Indonesia)\">+62(Indonesia)<\/option><option value=\"+60(Malaysia)\">+60(Malaysia)<\/option><option value=\"+65(Singapore)\">+65(Singapore)<\/option><option value=\"+84(Vietnam)\">+84(Vietnam)<\/option><option value=\"+7(Russia)\">+7(Russia)<\/option><option value=\"+52( Mexico)\">+52( Mexico)<\/option><option value=\"+55(Brazil)\">+55(Brazil)<\/option><option value=\"+54(Argentina)\">+54(Argentina)<\/option><option value=\"+27(South Africa)\">+27(South Africa)<\/option><option value=\"+966(Saudi Arabia)\">+966(Saudi Arabia)<\/option><option value=\"+90(Turkey)\">+90(Turkey)<\/option><option value=\"+974(Qatar)\">+974(Qatar)<\/option><\/select><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap tel-kinkyu\"><input type=\"text\" name=\"tel-kinkyu\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"02-107-1039\" \/><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap name-kinkyu\"><input type=\"text\" name=\"name-kinkyu\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Name\" \/><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap relation-kinkyu\"><input type=\"text\" name=\"relation-kinkyu\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Relationship\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Do you have any chronic diseases?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap jibyo\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"jibyo\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"jibyo\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap jibyo2\"><input type=\"text\" name=\"jibyo2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"The name of diesease\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Do you take any medicine regulrarly?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap medicine\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medicine\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medicine\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap medicine2\"><input type=\"text\" name=\"medicine2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Medicine name\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Have you ever got surgery or admit before?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap history\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"history\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"history\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><\/p>\n<div class=\"historybox\">\n      <span class=\"wpcf7-form-control-wrap history2\"><input type=\"text\" name=\"history2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"The name of Disease\" \/><\/span><br \/>\n      <span class=\"wpcf7-form-control-wrap history3\"><input type=\"text\" name=\"history3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"When?\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Do you have any allergy for medicines?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap allergy1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"allergy1\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergy1\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><\/p>\n<div class=\"allergy_box1\">\n      <span class=\"wpcf7-form-control-wrap allergy1-2\"><input type=\"text\" name=\"allergy1-2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"What allergy?\" \/><\/span><br \/>\n      <span class=\"wpcf7-form-control-wrap allergy1-3\"><input type=\"text\" name=\"allergy1-3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Symptom\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Do you have any allergy for food?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap allergy2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"allergy2\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergy2\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><\/p>\n<div class=\"allergy_box2\">\n      <span class=\"wpcf7-form-control-wrap allergy2-2\"><input type=\"text\" name=\"allergy2-2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"What allergy?\" \/><\/span><br \/>\n      <span class=\"wpcf7-form-control-wrap allergy2-3\"><input type=\"text\" name=\"allergy2-3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Symptom\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Do you have any other allergy?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap allergy3\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"allergy3\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergy3\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><\/p>\n<div class=\"allergy_box3\">\n      <span class=\"wpcf7-form-control-wrap allergy3-2\"><input type=\"text\" name=\"allergy3-2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"What allergy?\" \/><\/span><br \/>\n      <span class=\"wpcf7-form-control-wrap allergy3-3\"><input type=\"text\" name=\"allergy3-3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Symptom\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Has your kid ever had unusual reaction after taking medicine?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap medicine-side\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medicine-side\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medicine-side\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap medicine-side2\"><input type=\"text\" name=\"medicine-side2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Details\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Please select the disease your kid has suffered before and fill out the age of it.<\/div>\n<div class=\"required nini\">Optional<\/div>\n<\/div>\n<div class=\"forminput checkbox\">\n    <span class=\"wpcf7-form-control-wrap disease1\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"disease1[]\" value=\"Exanthem subitum\" \/><span class=\"wpcf7-list-item-label\">Exanthem subitum<\/span><\/label><\/span><\/span><\/span> <span class=\"wpcf7-form-control-wrap age1\"><input type=\"text\" name=\"age1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text number\" aria-invalid=\"false\" placeholder=\"10\" \/><\/span>\u3000years old<br \/>\n    <span class=\"wpcf7-form-control-wrap disease2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"disease2[]\" value=\"Measles\" \/><span class=\"wpcf7-list-item-label\">Measles<\/span><\/label><\/span><\/span><\/span> <span class=\"wpcf7-form-control-wrap age2\"><input type=\"text\" name=\"age2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text number\" aria-invalid=\"false\" placeholder=\"10\" \/><\/span>\u3000years old<br \/>\n    <span class=\"wpcf7-form-control-wrap disease3\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"disease3[]\" value=\"Rubella\" \/><span class=\"wpcf7-list-item-label\">Rubella<\/span><\/label><\/span><\/span><\/span> <span class=\"wpcf7-form-control-wrap age3\"><input type=\"text\" name=\"age3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text number\" aria-invalid=\"false\" placeholder=\"10\" \/><\/span>\u3000years old<br \/>\n    <span class=\"wpcf7-form-control-wrap disease4\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"disease4[]\" value=\"Chickenpox\" \/><span class=\"wpcf7-list-item-label\">Chickenpox<\/span><\/label><\/span><\/span><\/span> <span class=\"wpcf7-form-control-wrap age4\"><input type=\"text\" name=\"age4\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text number\" aria-invalid=\"false\" placeholder=\"10\" \/><\/span>\u3000years old<br \/>\n    <span class=\"wpcf7-form-control-wrap disease5\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"disease5[]\" value=\"Asthmatic Bronchitis\" \/><span class=\"wpcf7-list-item-label\">Asthmatic Bronchitis<\/span><\/label><\/span><\/span><\/span> <span class=\"wpcf7-form-control-wrap age5\"><input type=\"text\" name=\"age5\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text number\" aria-invalid=\"false\" placeholder=\"10\" \/><\/span>\u3000years old<br \/>\n    <span class=\"wpcf7-form-control-wrap disease6\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"disease6[]\" value=\"Seizure\u30fbFebrile seizure\" \/><span class=\"wpcf7-list-item-label\">Seizure\u30fbFebrile seizure<\/span><\/label><\/span><\/span><\/span> <span class=\"wpcf7-form-control-wrap age6\"><input type=\"text\" name=\"age6\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text number\" aria-invalid=\"false\" placeholder=\"10\" \/><\/span>\u3000years old\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Are there any other severe diseases which you kid has ever had?<\/div>\n<div class=\"required nini\">Optional<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap other-disease\"><input type=\"text\" name=\"other-disease\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Gestational age<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap week\"><input type=\"text\" name=\"week\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"40\" \/><\/span>\u3000weeks\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Weight when birth<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap weight\"><input type=\"text\" name=\"weight\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required number\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"3000\" \/><\/span>\u3000gram\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Please select the following.<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap bunbetsu\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bunbetsu\" value=\"Cesarean Section\" \/><span class=\"wpcf7-list-item-label\">Cesarean Section<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"bunbetsu\" value=\"Natural or Epidural Birth\" \/><span class=\"wpcf7-list-item-label\">Natural or Epidural Birth<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bunbetsu\" value=\"No sure\" \/><span class=\"wpcf7-list-item-label\">No sure<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Asphyzia experience<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap bunbetsu2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bunbetsu2\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"bunbetsu2\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bunbetsu2\" value=\"Not sure\" \/><span class=\"wpcf7-list-item-label\">Not sure<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Does your kid has juandice when birth?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap bunbetsu3\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"bunbetsu3\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"bunbetsu3\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"bunbetsu3\" value=\"Not sure\" \/><span class=\"wpcf7-list-item-label\">Not sure<\/span><\/label><\/span><\/span><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Do you want to have Free vaccine consultation today?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap vaccine\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"vaccine\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"vaccine\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><\/p>\n<p style=\"margin-top: 10px; line-height: 1.3;\">Depending on the level of congestion, it may take some time before we can assist you with your vaccine consultation. Thank you for your understanding in advance.<\/p>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div> How did you come to know us?<\/div>\n<div class=\"required\">Required<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap kikkake\"><select name=\"kikkake\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Please select\">Please select<\/option><option value=\"Refferal from friends\">Refferal from friends<\/option><option value=\"Refferal from company\">Refferal from company<\/option><option value=\"Google\">Google<\/option><option value=\"WISE freepaper\">WISE freepaper<\/option><option value=\"Poster in front of clinic\">Poster in front of clinic<\/option><option value=\"Brochure\">Brochure<\/option><option value=\"LINE\">LINE<\/option><option value=\"Instagram\">Instagram<\/option><option value=\"X\">X<\/option><option value=\"Facebook\">Facebook<\/option><option value=\"Bangkok Medical Infromation\">Bangkok Medical Infromation<\/option><\/select><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>If you need to fill following info on receipt, please fill them out.<\/div>\n<div class=\"required nini\">Optional<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap re-name\"><input type=\"text\" name=\"re-name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Name\" \/><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap re-address\"><input type=\"text\" name=\"re-address\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"Address on receipt\" \/><\/span><br \/>\n    <span class=\"wpcf7-form-control-wrap re-id\"><input type=\"text\" name=\"re-id\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"TAX-ID\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Inquiry<\/div>\n<div class=\"required nini\">Optional<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap others\"><textarea name=\"others\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" placeholder=\"If you have any questions or requests, please write them down.\"><\/textarea><\/span>\n  <\/div>\n<\/div>\n<div class=\"shashin\">If you have the following photos, please attach them.<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Passport<\/div>\n<div class=\"required nini\">Optional<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap passport\"><input type=\"file\" name=\"passport\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf\" aria-invalid=\"false\" \/><\/span><br \/>\n    <img decoding=\"async\" id=\"passportPreview\" src=\"#\" alt=\"\u30d1\u30b9\u30dd\u30fc\u30c8\u30d7\u30ec\u30d3\u30e5\u30fc\" style=\"display:none; width:200px; height:auto;\">\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>Insurance<\/div>\n<div class=\"required nini\">Optional<\/div>\n<\/div>\n<div class=\"forminput\">\n    <span class=\"wpcf7-form-control-wrap hoken\"><input type=\"file\" name=\"hoken\" size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.png,.gif,.pdf\" aria-invalid=\"false\" \/><\/span><br \/>\n    <img decoding=\"async\" id=\"hokenPreview\" src=\"#\" alt=\"\u4fdd\u967a\u8a3c\u30d7\u30ec\u30d3\u30e5\u30fc\" style=\"display:none; width:200px; height:auto;\">\n  <\/div>\n<\/div>\n<div class=\"policy\">\n  <span class=\"wpcf7-form-control-wrap agree\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"agree\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I agree to the <a href=\"https:\/\/dymclinic.com\/en\/privacy_policy\/\" target=\"_blank\">privacy policy<\/a>.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"policy\">\n  <span class=\"wpcf7-form-control-wrap agree\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"agree\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">Please confirm your input.<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"submit\">\n  <input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control wpcf7-submit\" \/>\n<\/div>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"pages\/registration-children.php","meta":{"footnotes":""},"acf":[],"_links":{"self":[{"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/pages\/731"}],"collection":[{"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/comments?post=731"}],"version-history":[{"count":3,"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/pages\/731\/revisions"}],"predecessor-version":[{"id":754,"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/pages\/731\/revisions\/754"}],"wp:attachment":[{"href":"https:\/\/dymclinic.com\/en\/wp-json\/wp\/v2\/media?parent=731"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}