Registration form – Hospital for Tropical Diseases

Registration form

Please fill all information in the fields below

Patient's Name *

First

Middle

Last

Date of Birth *

Age *

Sex *

Male
Female

National Identification number

Passport Number *

Nationality *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Address (In Thailand) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Address in Thailand (Hotel, Hostel, apartment)

Email Address *

Phone *

Person to be notified in case of emergency and phone no. *

Name, relationship and phone number

Phone *

l hereby certifies that the information given above is correct and I take full responsibility for any incorrect information.

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