Payment Form

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

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

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.

* Please check this box to confirm that you have read, understood and agree to the Terms and Conditions and Privacy Policy above payment of Bangkok Hospital Phuket.