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Contact Us
Reservation form
Reservation form
Name：
Male
Female
date of birth：
Republic of China
year
month
day
Address：
Career：
company phone：
mobile phone：
Email：
Line ID：
Contracted company name：
employee ID：
Introducer：
Relationship with introducer：
Please answer the following questions and let us make proper arrangements for you：
1. Have you ever implanted teeth before?
Yes
No
2. How many teeth do you expect to implant?
/ tooth
3. Which tooth block do you want to implant?
Upper left
Lower left
Top right
Bottom right
4. Which area of the clinic do you want to implant?
North Kaohsiung
South Kaohsiung
Taipei City
New Taipei City
Taichung City
Other areas
5. Which time period do you prefer for evaluation/implantation?
on Monday
on Tuesday
on Wednesday
on Thursday
on Friday
9:30~12:00 in the morning
2:30~6:00 in the afternoon
Other time
6. How easy is it for you to contact?
Line
Email
TEL
Mobile phone newsletter
7. How easy is it for you to contact?
9:30~12:00 in the morning
Lunch break 12:00~1:30
1:30~6:00 in the afternoon
7:00~9:00 in the evening
Other time
Message：
Contact Information：
