Appointment | Bangkok Hospital Phuket – International Hospitals in Thailand

ElectrophysiologyMedicine

For appointments, please contact 076-254425

Preferred date and time option 1
DD slash MM slash YYYY
Time
Preferred date and time option 2
DD slash MM slash YYYY
Time
Your Medical Problem or Symptoms*
Supporting Documents (optional)
Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.
Patient Information*
First Last name
Date Of Birth*
DD slash MM slash YYYY
Gender
Have you been our patient before?*
- Yes
- No
HN Number (if remembered)
Nationality
Passport Number
Email*
Phone
Please note that this is not a confirmation of your appointment. The confirmation will be sent to your email within 24 hours.
{all_fields}
This field is hidden when viewing the form
Comprehensive Cancer Care
- true
- false
This field is hidden when viewing the form
Confirm
- Please note that this is not a confirmation of your appointment. The confirmation will be sent to your email within 24 hours.
I voluntarily agree to allow the healthcare staff at the hospital to provide care, treatment and procedure according to the standard of practice. I also agree to the healthcare staff access my health information in regard to the provided care, treatment and procedure. I acknowledge and understand that I have been informed about Declaration of Patient's Rights and Privacy Policy