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
 
 
 
 
 
 
 
 
     
 
© 2007-2008. Bangkok Hospital Phuket. All Rights Reserved. Update : Today :