วันตรวจ วัน........ที่.........เดือ

วันตรวจ วัน........ที่.........เดือน.............พ.ศ. 2557
ชื่อสกุล หัตถการ...............

สิทธิ์การรักษา....................... แพทย์ผู้ทำ...........

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The date for screening grain ........ months ............. 2557 (2014)
hatthakan

............... last name
privileges maintain ....................... Doctors who do ...........

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Check on the ......... day ........ BE Month ............. 2557
............... surname Operative treatment ....................... rights Doctors who do ...........

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The test day,... Who... Months... To... The 2557
family name operative.......

the right treatment............ doctors who do... To..

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