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Consultation Details

Please add as many details possible about your medical condition and past medical history,
this will help our physicians giving you a more precise and accurate evaluation.

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

* is required

* Your medical inquiry details :

Medical History ( If has ) :

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).

Personal Details

* First name :

* Last name :

* Telephone :

Example 0809999999

* Former patient :

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> No

* Your Country :

* E-mail :

* Convenient to contact or get back to you the way : * Convenient to contact or get back to you the way :

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> Telephone

* Security Code :

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