ASQ EN New Patient registration

Underlying disease and current medication

No

Yes

Please identify

Health care coverage / Social security (contracted hospital)

For social security : would you like us refer you to contracted hospital ?

Yes, I prefer

No, I dont

The destination after 14 days of quarantine, such as hotel name and etc. *

Please attach file for the COVID-19 test report

Maximum upload size: 6MB

---Upload passport picture---

Upload your passport picture *

Maximum upload size: 6MB

---Insurance---

Would you like to use your insurance? *

No

Yes

Upload your insurance card or document *

Maximum upload size: 6MB

---Allergy---

Allergy: Have you any drug or food allergies? *

No known allergy

Yes

If yes, please specify *

---Patient Information---

Title *

Name *

Middle name

Last name *

Date of Birth (DD/MM/YYYY) *

Age

Sex *

Male

Female

Marital Status

Single

Married

OtherOther

Nationality *

Religion

Passport No./ Identify card No. *

Primary Language

---Address in Thailand---

Are you currently in Thailand? *

No

Yes

Where do you stay? *

Hotel

Apartment/Condominium

Address *

Zip code *

Hotel name *

Room number *

---Permanent Address---

Permanent address *

Country *

Zip code *

---Contact---

Country code

Contact number/ Telephone. *

Do you have Thai contact number? *

No

Yes

Thai contact number

E-mail address *

I agree to receive Hospital News

Via SMS only

Via E-mail only

Both SMS and E-mail

Not allowed

---Emergency contact person---

Next of kin name *

Relationship to patient *

Phone No. *

I acknowledge and do fully understand the Patient’s Right Declaration. I agree to the performance of any medical treatments and dental examinations. I agree that all of my health information treatment and investigation would only be revealed with doctors, nurses and staffs who are involved.

I was accepted that, if I do not present any document for identify myself. All of my health report, laboratory result and other medical record will not be printed and verified by the hospital. And it will be available when I present my any identify document.

---Signature---

Signature *

Clear

Online Registration

Please fill in English

Documents required: Please prepare your passport picture and upload the picture in this page.

---Upload passport picture---

---Insurance---

---Allergy---

---Patient Information---

---Address in Thailand---

---Permanent Address---

---Contact---

---Emergency contact person---

---Signature---

After press submit button, Please wait to upload the information within 1 minute.

Online Registration

Please fill in English

Documents required: Please prepare your passport picture and upload the picture in this page.

---Upload passport picture---

---Insurance---

---Allergy---

---Patient Information---

---Address in Thailand---

---Permanent Address---

---Contact---

---Emergency contact person---

---Signature---

After press submit button, Please wait to upload the information within 1 minute.

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