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中医线上咨询申请TCM Online Consultation

TCM Consultation Intake Form

【复诊患者】请直接通过 WhatsApp 联系我们获取专属复诊报价与追踪,无需重复填写此单。 [Returning Patients] Please contact us directly via WhatsApp for follow-ups. No need to refill this form.

本问诊单目前以中文填写为主。如需英文协助,请通过 WhatsApp 联系我们安排。 This form is primarily completed in Chinese. For English assistance, please contact us via WhatsApp.

本平台提供专业中医线上咨询资料收集服务。所有资料将由大马注册中医师亲自查阅并制定专属调理方案。 This platform collects data for professional TCM online consultations. All data will be reviewed personally by a registered TCM practitioner to create a custom plan.

基本资料Personal Information

Profile Setup

用于身份核对、预约确认和病历记录。For identity verification, appointment confirmation, and clinical record keeping.

紧急联系人Emergency Contact

咨询偏好Consultation Preferences

Preferences

主诉Main Complaint

Chief Complaint

5

症状情况Symptom Details

Symptom Inventory

选择看诊配套与付款Select Consult Plan & Pay

Checkout

提交流程Submission Process

【重要】请在点击第一步前往 Stripe 完成付款后,务必切回此网页点击「第二步」发送您的完整病历资料。
若有舌象或检查报告,请直接在 WhatsApp 附上图片/PDF。
[Important] After completing payment via Step 1, you must return to this page and click "Step 2" to submit your medical record.
Please attach tongue photos or lab reports directly in WhatsApp.