Doctor2Go Intake Form

Medical Certificate Form

Fill in the patient and consultation details, then generate the certificate and receipt preview below.

Patient Information

Consultation Details

Medical Findings

Medical Advice

Additional Remarks

Doctor Information

Payment Details

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MEDICAL CERTIFICATION

Certificate No.: DG-2026-0029

Date of Issue: 20/02/2026

1. Patient Information:

Full Name: Joshua Itsuki Ohashi
Birthdate: 30/04/2014
Nationality: Japan
ID/Passport No.: -
Gender: Male

2. Medical Consultation Details:

Date of Examination: 20/02/2026
Place of Examination: Hotel: Emporium Suites Room No.: 4125

3. Medical Findings:

Chief Complaint: Multiple rashes along the body after shower with itching
History / Clinical Findings: Multiple erythematous, edematous wheals with well-defined borders, blanchable on pressure, and pruritic.
Diagnosis / ICD-10: Acute Urticaria of unknown etiology

Treatment / Investigation:

☑ Medication: Elomet lotion, CPM
☐ Investigation:
☐ Procedure / Operation:

4. Medical Advice:

☑ Fit to travel

☐ Fit to fly

☐ Fit to work

☐ Advised hospital evaluation

☐ Other
☐ Unfit to travel until
☐ Unfit to fly until
☐ Unfit to work until

5. Remarks (if any):

6. Doctor's Certification:

I hereby certify that I have personally examined and treated the above patient. The information provided herein is true and accurate to the best of my medical knowledge.

Physician's Name: Dr.Wirach Wacharakaroon
Signature : Doctor signature
Medical License No : 14606
Date : 20/02/2026
QR

Scan to verify

This is a digitally issued medical certificate with a valid electronic signature and verification QR code. No physical stamp is required. Please scan the QR code to verify issuance through the Doctor2GO system.

Doctor2GO - Registered Office: 230/7 Sukhumvit 20 Road, Klongtoey, Klongtoey, Bangkok 10110, Thailand

24/7 Hotline: +66 85 663 0 663 | Email: support@doctor2go.net | Website: www.doctor2go.net


RECEIPT

Certificate No.: DGR-2026-0029

Date of Issue: 20/02/2026

Payment Method: ☐ Cash ☑ Credit Card ☐ Bank Transfer ☐ Hotel Charge (Room No. ...............)

1. Patient / Payer Information

Full Name: Joshua Itsuki Ohashi
ID/Passport No.: -
Place of Examination: Hotel: Emporium Suites Room No.: 4125

2. Itemized Medical Services

Description Qty Unit Price (THB) Amount (THB)
Doctor Consultation Fee 1 4,500.00 4,500.00
Nursing Fee 0 0.00 0.00
Procedure Fee 0 0.00 0.00
Medication & Supplies 1 1,500.00 1,500.00
Medical Certificate Fee 0 0.00 0.00
Subtotal: 6,000.00
Discount: 0.00
Net Total: 6,000.00
VAT: 0.00
Grand Total: 6,000.00

3. Authorized Signature

Authorized by:
Signature: Receipt signature
Date: 20/02/2026
QR

Scan to verify

This is a digitally issued medical certificate with a valid electronic signature and verification QR code. No physical stamp is required. Please scan the QR code to verify issuance through the Doctor2GO system.

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