Appointment | E-Payment | Events & Seminar | Interview the Patients | FAQ | Site Map
 
Go to home page Register Login
Payment Online at Bangkok Hospital Phuket
The Hospital Centers & Clinics Find Doctor Patient Center Programs & Packages Contact Us
Home » Patient Center » Appointment
 
 
 
  Appointment Form
 

Indicates essential personal information
Enter Code Show Now* :
 
Passport No./ID :
 
Please Spectify Treatment* :
 
Please Spectify appointment date and time* :
  Day : Month : Year :
Allergy to* :
  
1. Drug : Not Known None
   
Yes (Please specity)
   
2. Food : Not Known None
   
Yes (Please specity)
   
3. Other : Not Known None
   
Yes (Please specity)
First Name* :  
 
Middle Name :
  
Family Name/Last Name* :
 
Gender* :
  
Male Female
Date of Birth (dd/mm/yyy)* :
  Day : Month : Year :
Age* :
 
Marital Status :
  
Single Married Divorced Widowed Priest / N
Occupation :
  
Nationality* :
  
Religion :
  
Detail of document identification :
  
ID Card Driver's License Passport
 
Others :
 
No document because :
     
     
Contact Information
     
HN :
 If you know
Present Address (in Thailand)  
or Hotel name :
  Tel :
Permanent Address* :
 
Tel. (Home) :
  
Tel. (Office) :
  
Tel. (Mobile) :
  
E-mail* :
  
How long have you been living at  
the present address? :
  
Tourist/Short visit 1 Year 1-5 Years >5 Years
Permanent Resident
Emergency Contact Person :   Name :
Relationship:
    Tel :
Mobile :
E-mail :
Insurance Company (if any) :
   1. 2.
Contract Company (if any) :
   1. 2.
     
   
 
 
 
 
Top
» Appointment
» E-payment
» Concierge Services
» Hospital Facilities
» Medical Tourism
» Member Zone
» Patient Services
 
 
 
 
 
 
 
 
     
 

Job Opportunities | Location | Insurance & Alliance | Perfect Diamond Card | Special Occasion | Link | Significant Events
© 2007-2008. Bangkok Hospital Phuket. All Rights Reserved. Update : Today :