New Patient Registration · Bang Bo Hospital

Please fill in this form. Fields marked * are required.

1. Personal information

First name *

As in your passport or document (English letters)

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Last name (optional)

Leave blank if you have none

Sex *

♂ Male ♀ Female

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Date of birth *

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Nationality *

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Phone number *

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Document type (optional) Document number (optional) Father's name (optional) Mother's name (optional)

Where you live now *

House number, road, or a nearby place (e.g. near ... market)

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Province * District * Sub-district *

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📮

Reason for visit *

Health check for workMedical treatment

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Date you will come to the hospital *

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Photo of your passport or ID document *

Take a photo of the page with your picture and name. The whole page must be clear.

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Photo of your face (optional)

Who is filling in this form? *

MyselfEmployer / companyAnother person (relative, friend, interpreter)

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