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Appointment Details

Please note this form is for regular appointments.

For urgent appointments, please call the hospital at : HOTLINE (+66) 8522 38888

* is required

Speciality :

Doctors :

Date and Time :

* Additional Note :

Supporting Files :

If you have any supporting files please attach these below.

The file size can not exceed 5 MB. (Lassen specific files .zip, .pdf, .rar .jpg .jpeg .gif .png only).

Patient Details

* Patient Name :

* Patient Surname :

* Gender :

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> Female

* Date of Birth :

* Nationality :

Former Vejthani patient ? :

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> No

* Hospital Number / HN # : * Hospital Number / HN # : ( If know )

- (If know)

Telephone Number :

* Mobile phone Number :

Example 0809999999

Fax :

* Email :

* Security Code :

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