EN Online Registration

---Allergy---

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? *

---Emergency contact person---


---Signature---


---Upload passport with your signature---

Your Passport (Please photocopy bio data page and sign) *
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