EN Online Registration
Upload your passport picture *
Maximum upload size: 6MB
Would you like to use your insurance? *
Upload your insurance card or document *
Maximum upload size: 6MB
Allergy: Have you any drug or food allergies? *

---Patient Information---

Title *
Sex *
Marital Status
Religion

---Address in Thailand---

Are you currently in Thailand? *
Where do you stay? *

---Permanent Address---


---Contact---

Do you have Thai contact number? *
I agree to receive Hospital News

---Emergency contact person---

      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---


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