{"id":719,"date":"2024-11-19T02:26:43","date_gmt":"2024-11-19T02:26:43","guid":{"rendered":"https:\/\/dymclinic.com\/th\/?page_id=719"},"modified":"2025-04-21T07:49:09","modified_gmt":"2025-04-21T07:49:09","slug":"registration-form-for-adults","status":"publish","type":"page","link":"https:\/\/dymclinic.com\/th\/registration-form-for-adults\/","title":{"rendered":"\u0e01\u0e32\u0e23\u0e25\u0e07\u0e17\u0e30\u0e40\u0e1a\u0e35\u0e22\u0e19\u0e2a\u0e33\u0e2b\u0e23\u0e31\u0e1a\u0e1c\u0e39\u0e49\u0e43\u0e2b\u0e0d\u0e48"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f721-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=\"\/th\/wp-json\/wp\/v2\/pages\/719#wpcf7-f721-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=\"721\" \/>\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-f721-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>\u0e40\u0e1e\u0e28<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\">\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01<\/option><option value=\"\u0e0a\u0e32\u0e22\">\u0e0a\u0e32\u0e22<\/option><option value=\"\u0e2b\u0e0d\u0e34\u0e07\">\u0e2b\u0e0d\u0e34\u0e07<\/option><option value=\"\u0e2d\u0e37\u0e48\u0e19\u0e46\">\u0e2d\u0e37\u0e48\u0e19\u0e46<\/option><\/select><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e0a\u0e37\u0e48\u0e2d(\u0e20\u0e32\u0e29\u0e32\u0e2d\u0e31\u0e07\u0e01\u0e24\u0e29)<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"YAMADA\" \/><\/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=\"TARO\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e0a\u0e37\u0e48\u0e2d(\u0e20\u0e32\u0e29\u0e32\u0e44\u0e17\u0e22)<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/div>\n<\/div>\n<div class=\"forminput namebox\">\n    <span class=\"wpcf7-form-control-wrap familythai\"><input type=\"text\" name=\"familythai\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u0e19\u0e32\u0e21\u0e2a\u0e01\u0e38\u0e25\" \/><\/span><span class=\"wpcf7-form-control-wrap firstthai\"><input type=\"text\" name=\"firstthai\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"\u0e0a\u0e37\u0e48\u0e2d\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e27\u0e31\u0e19-\u0e40\u0e14\u0e37\u0e2d\u0e19-\u0e1b\u0e35\u0e40\u0e01\u0e34\u0e14<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e1b\u0e35\">\u0e1b\u0e35<\/option><option value=\"1930\">1930<\/option><option value=\"1931\">1931<\/option><option value=\"1932\">1932<\/option><option value=\"1933\">1933<\/option><option value=\"1934\">1934<\/option><option value=\"1935\">1935<\/option><option value=\"1936\">1936<\/option><option value=\"1937\">1937<\/option><option value=\"1938\">1938<\/option><option value=\"1939\">1939<\/option><option value=\"1940\">1940<\/option><option value=\"1941\">1941<\/option><option value=\"1942\">1942<\/option><option value=\"1943\">1943<\/option><option value=\"1944\">1944<\/option><option value=\"1945\">1945<\/option><option value=\"1946\">1946<\/option><option value=\"1947\">1947<\/option><option value=\"1948\">1948<\/option><option value=\"1949\">1949<\/option><option value=\"1950\">1950<\/option><option value=\"1951\">1951<\/option><option value=\"1952\">1952<\/option><option value=\"1953\">1953<\/option><option value=\"1954\">1954<\/option><option value=\"1955\">1955<\/option><option value=\"1956\">1956<\/option><option value=\"1957\">1957<\/option><option value=\"1958\">1958<\/option><option value=\"1959\">1959<\/option><option value=\"1960\">1960<\/option><option value=\"1961\">1961<\/option><option value=\"1962\">1962<\/option><option value=\"1963\">1963<\/option><option value=\"1964\">1964<\/option><option value=\"1965\">1965<\/option><option value=\"1966\">1966<\/option><option value=\"1967\">1967<\/option><option value=\"1968\">1968<\/option><option value=\"1969\">1969<\/option><option value=\"1970\">1970<\/option><option value=\"1971\">1971<\/option><option value=\"1972\">1972<\/option><option value=\"1973\">1973<\/option><option value=\"1974\">1974<\/option><option value=\"1975\">1975<\/option><option value=\"1976\">1976<\/option><option value=\"1977\">1977<\/option><option value=\"1978\">1978<\/option><option value=\"1979\">1979<\/option><option value=\"1980\">1980<\/option><option value=\"1981\">1981<\/option><option value=\"1982\">1982<\/option><option value=\"1983\">1983<\/option><option value=\"1984\">1984<\/option><option value=\"1985\">1985<\/option><option value=\"1986\">1986<\/option><option value=\"1987\">1987<\/option><option value=\"1988\">1988<\/option><option value=\"1989\">1989<\/option><option value=\"1990\">1990<\/option><option value=\"1991\">1991<\/option><option value=\"1992\">1992<\/option><option value=\"1993\">1993<\/option><option value=\"1994\">1994<\/option><option value=\"1995\">1995<\/option><option value=\"1996\">1996<\/option><option value=\"1997\">1997<\/option><option value=\"1998\">1998<\/option><option value=\"1999\">1999<\/option><option value=\"2000\">2000<\/option><option value=\"2001\">2001<\/option><option value=\"2002\">2002<\/option><option value=\"2003\">2003<\/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><\/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=\"\u0e40\u0e14\u0e37\u0e2d\u0e19\">\u0e40\u0e14\u0e37\u0e2d\u0e19<\/option><option value=\"\u0e21\u0e01\u0e23\u0e32\u0e04\u0e21\">\u0e21\u0e01\u0e23\u0e32\u0e04\u0e21<\/option><option value=\"\u0e01\u0e38\u0e21\u0e20\u0e32\u0e1e\u0e31\u0e19\u0e18\u0e4c\">\u0e01\u0e38\u0e21\u0e20\u0e32\u0e1e\u0e31\u0e19\u0e18\u0e4c<\/option><option value=\"\u0e21\u0e35\u0e19\u0e32\u0e04\u0e21\">\u0e21\u0e35\u0e19\u0e32\u0e04\u0e21<\/option><option value=\"\u0e40\u0e21\u0e29\u0e32\u0e22\u0e19\">\u0e40\u0e21\u0e29\u0e32\u0e22\u0e19<\/option><option value=\"\u0e1e\u0e24\u0e29\u0e20\u0e32\u0e04\u0e21\">\u0e1e\u0e24\u0e29\u0e20\u0e32\u0e04\u0e21<\/option><option value=\"\u0e21\u0e34\u0e16\u0e38\u0e19\u0e32\u0e22\u0e19\">\u0e21\u0e34\u0e16\u0e38\u0e19\u0e32\u0e22\u0e19<\/option><option value=\"\u0e01\u0e23\u0e01\u0e0e\u0e32\u0e04\u0e21\">\u0e01\u0e23\u0e01\u0e0e\u0e32\u0e04\u0e21<\/option><option value=\"\u0e2a\u0e34\u0e07\u0e2b\u0e32\u0e04\u0e21\">\u0e2a\u0e34\u0e07\u0e2b\u0e32\u0e04\u0e21<\/option><option value=\"\u0e01\u0e31\u0e19\u0e22\u0e32\u0e22\u0e19\">\u0e01\u0e31\u0e19\u0e22\u0e32\u0e22\u0e19<\/option><option value=\"\u0e15\u0e38\u0e25\u0e32\u0e04\u0e21\">\u0e15\u0e38\u0e25\u0e32\u0e04\u0e21<\/option><option value=\"\u0e1e\u0e24\u0e28\u0e08\u0e34\u0e01\u0e32\u0e22\u0e19\">\u0e1e\u0e24\u0e28\u0e08\u0e34\u0e01\u0e32\u0e22\u0e19<\/option><option value=\"\u0e18\u0e31\u0e19\u0e27\u0e32\u0e04\u0e21\">\u0e18\u0e31\u0e19\u0e27\u0e32\u0e04\u0e21<\/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=\"\u0e27\u0e31\u0e19\">\u0e27\u0e31\u0e19<\/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>\u0e40\u0e1a\u0e2d\u0e23\u0e4c\u0e42\u0e17\u0e23\u0e28\u0e31\u0e1e\u0e17\u0e4c<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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>\u0e2d\u0e35\u0e40\u0e21\u0e25\u0e25\u0e4c<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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>\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19\u0e17\u0e35\u0e48\u0e43\u0e0a\u0e49<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\">\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01<\/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>\u0e17\u0e35\u0e48\u0e2d\u0e22\u0e39\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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>\u0e40\u0e1a\u0e2d\u0e23\u0e4c\u0e15\u0e34\u0e14\u0e15\u0e48\u0e2d\u0e09\u0e38\u0e01\u0e40\u0e09\u0e34\u0e19<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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><\/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=\"\u0e0a\u0e37\u0e48\u0e2d\" \/><\/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=\"\u0e04\u0e27\u0e32\u0e21\u0e40\u0e01\u0e35\u0e48\u0e22\u0e27\u0e02\u0e49\u0e2d\u0e07\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e21\u0e35\u0e42\u0e23\u0e04\u0e40\u0e23\u0e37\u0e49\u0e2d\u0e23\u0e31\u0e07\u0e2b\u0e23\u0e37\u0e2d\u0e42\u0e23\u0e04\u0e1b\u0e23\u0e30\u0e08\u0e33\u0e15\u0e31\u0e27\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"jibyo\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/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=\"\u0e0a\u0e37\u0e48\u0e2d\u0e42\u0e23\u0e04\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e21\u0e35\u0e22\u0e32\u0e17\u0e35\u0e48\u0e17\u0e32\u0e19\u0e40\u0e1b\u0e47\u0e19\u0e1b\u0e23\u0e30\u0e08\u0e33\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medicine\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/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=\"\u0e0a\u0e37\u0e48\u0e2d\u0e22\u0e32\" \/><\/span>\n  <\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e40\u0e04\u0e22\u0e1c\u0e48\u0e32\u0e15\u0e31\u0e14\u0e2b\u0e23\u0e37\u0e2d\u0e19\u0e2d\u0e19\u0e42\u0e23\u0e07\u0e1e\u0e22\u0e32\u0e1a\u0e32\u0e25\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"history\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/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=\"\u0e0a\u0e37\u0e48\u0e2d\u0e42\u0e23\u0e04\" \/><\/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=\"\u0e40\u0e21\u0e37\u0e48\u0e2d\u0e44\u0e2b\u0e23\u0e48\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e21\u0e35\u0e1b\u0e23\u0e30\u0e27\u0e31\u0e15\u0e34\u0e41\u0e1e\u0e49\u0e22\u0e32\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergy1\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/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=\"\u0e0a\u0e37\u0e48\u0e2d\u0e22\u0e32\" \/><\/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=\"\u0e2d\u0e32\u0e01\u0e32\u0e23\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e21\u0e35\u0e1b\u0e23\u0e30\u0e27\u0e31\u0e15\u0e34\u0e41\u0e1e\u0e49\u0e2d\u0e32\u0e2b\u0e32\u0e23\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergy2\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/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=\"\u0e0a\u0e37\u0e48\u0e2d\u0e2d\u0e32\u0e2b\u0e32\u0e23\u0e17\u0e35\u0e48\u0e41\u0e1e\u0e49\" \/><\/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=\"\u0e2d\u0e32\u0e01\u0e32\u0e23\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e21\u0e35\u0e2d\u0e32\u0e01\u0e32\u0e23\u0e41\u0e1e\u0e49\u0e2d\u0e22\u0e48\u0e32\u0e07\u0e2d\u0e37\u0e48\u0e19\u0e2d\u0e35\u0e01\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergy3\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/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=\"\u0e2a\u0e34\u0e48\u0e07\u0e17\u0e35\u0e48\u0e41\u0e1e\u0e49\" \/><\/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=\"\u0e2d\u0e32\u0e01\u0e32\u0e23\" \/><\/span>\n    <\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e2a\u0e39\u0e1a\u0e1a\u0e38\u0e2b\u0e23\u0e35\u0e48\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap smoking\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"smoking\" value=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"smoking\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/span><\/label><\/span><\/span><\/span><\/p>\n<div class=\"smokingbox\"><span class=\"wpcf7-form-control-wrap smoking2\"><input type=\"text\" name=\"smoking2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"10\" \/><\/span><span class=\"sub-form\"> \u0e21\u0e27\u0e19 \/ 1\u0e27\u0e31\u0e19<\/span><\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e14\u0e37\u0e48\u0e21\u0e41\u0e2d\u0e25\u0e01\u0e2d\u0e2e\u0e2d\u0e25\u0e4c\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/div>\n<\/div>\n<div class=\"forminput radio\">\n    <span class=\"wpcf7-form-control-wrap drink\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"drink\" value=\"\u0e44\u0e21\u0e48\u0e21\u0e35\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e21\u0e35<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"drink\" value=\"\u0e21\u0e35\" \/><span class=\"wpcf7-list-item-label\">\u0e21\u0e35<\/span><\/label><\/span><\/span><\/span><\/p>\n<div class=\"drinkbox\"><span class=\"wpcf7-form-control-wrap drink2\"><input type=\"text\" name=\"drink2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"5\" \/><\/span><span class=\"sub-form\"> \u0e41\u0e01\u0e49\u0e27,\u0e02\u0e27\u0e14,\u0e01\u0e23\u0e30\u0e1b\u0e4b\u0e2d\u0e07 \/ 1\u0e27\u0e31\u0e19<\/span><span class=\"wpcf7-form-control-wrap drink3\"><input type=\"text\" name=\"drink3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"\u0e1b\u0e23\u0e30\u0e40\u0e20\u0e17\u0e41\u0e2d\u0e25\u0e01\u0e2d\u0e2e\u0e2d\u0e25\u0e4c\" \/><\/span><\/div>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e17\u0e48\u0e32\u0e19\u0e21\u0e35\u0e04\u0e27\u0e32\u0e21\u0e1b\u0e23\u0e30\u0e2a\u0e07\u0e04\u0e4c\u0e08\u0e30\u0e1b\u0e23\u0e36\u0e01\u0e29\u0e32\u0e27\u0e31\u0e04\u0e0b\u0e35\u0e19\u0e2b\u0e23\u0e37\u0e2d\u0e44\u0e21\u0e48(\u0e44\u0e21\u0e48\u0e21\u0e35\u0e04\u0e48\u0e32\u0e43\u0e0a\u0e49\u0e08\u0e48\u0e32\u0e22)<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\" \/><span class=\"wpcf7-list-item-label\">\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"vaccine\" value=\"\u0e44\u0e21\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\" \/><span class=\"wpcf7-list-item-label\">\u0e44\u0e21\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23<\/span><\/label><\/span><\/span><\/span><\/p>\n<p style=\"margin-top: 10px; line-height: 1.3;\">\u0e2d\u0e32\u0e08\u0e15\u0e49\u0e2d\u0e07\u0e43\u0e0a\u0e49\u0e40\u0e27\u0e25\u0e32\u0e43\u0e19\u0e01\u0e32\u0e23\u0e1b\u0e23\u0e36\u0e01\u0e29\u0e32\u0e40\u0e23\u0e37\u0e48\u0e2d\u0e07\u0e27\u0e31\u0e04\u0e0b\u0e35\u0e19\u0e02\u0e36\u0e49\u0e19\u0e2d\u0e22\u0e39\u0e48\u0e01\u0e31\u0e1a\u0e04\u0e27\u0e32\u0e21\u0e2b\u0e19\u0e32\u0e41\u0e19\u0e48\u0e19\u0e02\u0e2d\u0e07\u0e1c\u0e39\u0e49\u0e23\u0e31\u0e1a\u0e1a\u0e23\u0e34\u0e01\u0e32\u0e23\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e02\u0e49\u0e32\u0e43\u0e08\u0e25\u0e48\u0e27\u0e07\u0e2b\u0e19\u0e49\u0e32\u0e14\u0e49\u0e27\u0e22\u0e04\u0e48\u0e30\/\u0e04\u0e23\u0e31\u0e1a<\/p>\n<\/p><\/div>\n<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e2a\u0e32\u0e40\u0e2b\u0e15\u0e38\u0e17\u0e35\u0e48\u0e21\u0e32\u0e40\u0e02\u0e49\u0e32\u0e23\u0e31\u0e1a\u0e01\u0e32\u0e23\u0e15\u0e23\u0e27\u0e08<\/div>\n<div class=\"required\">\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01\">\u0e01\u0e23\u0e38\u0e13\u0e32\u0e40\u0e25\u0e37\u0e2d\u0e01<\/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>\u0e2a\u0e33\u0e2b\u0e23\u0e31\u0e1a\u0e17\u0e48\u0e32\u0e19\u0e17\u0e35\u0e48\u0e15\u0e49\u0e2d\u0e07\u0e01\u0e32\u0e23\u0e43\u0e1a\u0e40\u0e2a\u0e23\u0e47\u0e08<\/div>\n<div class=\"required nini\">\u0e44\u0e21\u0e48\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e0a\u0e37\u0e48\u0e2d\u0e1c\u0e39\u0e49\u0e23\u0e31\u0e1a\" \/><\/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=\"\u0e17\u0e35\u0e48\u0e2d\u0e22\u0e39\u0e48\" \/><\/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>\u0e2a\u0e2d\u0e1a\u0e16\u0e32\u0e21\u0e40\u0e1e\u0e34\u0e48\u0e21\u0e40\u0e15\u0e34\u0e21<\/div>\n<div class=\"required nini\">\u0e44\u0e21\u0e48\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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=\"\u0e2b\u0e32\u0e01\u0e21\u0e35\u0e04\u0e33\u0e16\u0e32\u0e21\u0e2b\u0e23\u0e37\u0e2d\u0e02\u0e49\u0e2d\u0e2a\u0e07\u0e2a\u0e31\u0e22\u0e43\u0e14 \u0e46 \u0e01\u0e23\u0e38\u0e13\u0e32\u0e01\u0e23\u0e2d\u0e01\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\u0e25\u0e07\u0e43\u0e19\u0e41\u0e1a\u0e1a\u0e1f\u0e2d\u0e23\u0e4c\u0e21\"><\/textarea><\/span>\n  <\/div>\n<\/div>\n<div class=\"shashin\">\u0e2b\u0e32\u0e01\u0e04\u0e38\u0e13\u0e21\u0e35\u0e23\u0e39\u0e1b\u0e16\u0e48\u0e32\u0e22\u0e14\u0e31\u0e07\u0e15\u0e48\u0e2d\u0e44\u0e1b\u0e19\u0e35\u0e49 \u0e01\u0e23\u0e38\u0e13\u0e32\u0e41\u0e19\u0e1a\u0e21\u0e32<\/div>\n<div class=\"formpart\">\n<div class=\"formname\">\n<div>\u0e2b\u0e19\u0e31\u0e07\u0e2a\u0e37\u0e2d\u0e40\u0e14\u0e34\u0e19\u0e17\u0e32\u0e07<\/div>\n<div class=\"required nini\">\u0e44\u0e21\u0e48\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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>\u0e1a\u0e31\u0e15\u0e23\u0e1b\u0e23\u0e30\u0e01\u0e31\u0e19\u0e2a\u0e38\u0e02\u0e20\u0e32\u0e1e<\/div>\n<div class=\"required nini\">\u0e44\u0e21\u0e48\u0e08\u0e33\u0e40\u0e1b\u0e47\u0e19<\/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\">\u0e02\u0e49\u0e32\u0e1e\u0e40\u0e08\u0e49\u0e32\u0e15\u0e01\u0e25\u0e07\u0e15\u0e32\u0e21<a href=\"https:\/\/dymclinic.com\/th\/privacy_policy\/\" target=\"_blank\">\u0e19\u0e42\u0e22\u0e1a\u0e32\u0e22\u0e04\u0e27\u0e32\u0e21\u0e40\u0e1b\u0e47\u0e19\u0e2a\u0e48\u0e27\u0e19\u0e15\u0e31\u0e27<\/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\">\u0e01\u0e23\u0e38\u0e13\u0e32\u0e22\u0e37\u0e19\u0e22\u0e31\u0e19\u0e02\u0e49\u0e2d\u0e21\u0e39\u0e25\u0e02\u0e2d\u0e07\u0e04\u0e38\u0e13<\/span><\/label><\/span><\/span><\/span>\n<\/div>\n<div class=\"submit\">\n  <input type=\"submit\" value=\"\u0e2a\u0e48\u0e07\" 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.php","meta":{"footnotes":""},"acf":[],"_links":{"self":[{"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/pages\/719"}],"collection":[{"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/comments?post=719"}],"version-history":[{"count":4,"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/pages\/719\/revisions"}],"predecessor-version":[{"id":746,"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/pages\/719\/revisions\/746"}],"wp:attachment":[{"href":"https:\/\/dymclinic.com\/th\/wp-json\/wp\/v2\/media?parent=719"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}