BIOGRAPHICAL INFORMATION
Former BMC Patient:
Primary Language:
Hospital Number:
Secondary Languages:
Title:
Mr.
Mrs.
Miss.
Passport Number:
Sex:
Male
Female
Current Address:
First Name:
Telephone:
Last Name:
Mobile:
Date of Birth:
E-mail:
Nationality:
PATIENT
CLINICAL
INFORMATION
Allergies:
Treatments Received:
Present Illnesses:
Packages/Treatments Desired:
Past Major Illnesses:
METHOD OF PAYMENT
Health Insurance:
Transfer to Bangkok Hospital Account:
YOUR REQUEST FOR INFORMATION FROM THE HOPITAL
OTHER ASSISTANCE
Treatment Options:
Interpreter Required:
- Please Select -
English
Chinese
Vietnamese
Laos
Cambodian
Spanish
Duration of Stay:
Interpreter Required:
Cost Estimate:
Other:
TRANSPORTATION / SERVICES REQUEST
Arrange Air Travel:
Arrange Sight-seeing in Bangkok:
Arrange Hotel Stay in Bangkok:
Ambulance from Hospital:
Accompanying Members of your family:
Date and Time of Arrival:
Remarks:
Assistance Needed:
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