Payment Form

For your convenience, Bangkok Hospital Phuket arranges your online hospital bills for you and your beloveds. We accept MasterCard, Visa.

"*" indicates required fields

1. Payer Information

Please input name as on passport/ID card.

Prefix*

First Name*

Last Name*

ID Card or Passport No*

The address can be contacted*

Country of Residence*

Zip / Post Code*

Email*

Mobile Phone / Phone can be contact*

2. Payment Detail

Pay for Treatments / Operation / Deposit

Please Specify Treatment for Your Payment*

Payment Amount*

3. Patient Information

Please input name as on passport/ID card.

Prefix*

First Name*

Last Name*

Gender*

Male

Female

Nationality*

Date of Birth*

Month*

Year*

Patient Hospital Number

(Please indicate, if applicable)

Room Number

(Please indicate, if applicable)

Treatment / Appointment date*

4. Terms and Conditions

You shall verify the accuracy of the information in every step on this online payment form.

You certify that the information on this payment form is complete, true and accurate.

Bangkok Hospital Phuket reserves the rights to deny any liability for the mistaken payment because of your declaration, or because of your illegal payment.

Your transaction may not be fully completed until the bank approves your payment.

1. Payer Information

2. Payment Detail

3. Patient Information

4. Terms and Conditions

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