First Name            Last Name

email address

Street Address     Street Address (cont.)

City/Town             State/County/Province

Postal Code/Zip    Country

Nationality            Passport Number

Telephone             9am to 11am 11am to 12 Noon 12 Noon to 2pm 2pm to 4pm 4pm to 6pm 6pm to 8pm 8pm to 9pm Do not call Good time to call

Procedure(s)

Bangkok International Bumrungrad in Bangkok Bangkok Hospital in Pattaya Bangkok Hospital in Phuket Samitivej Hospital in Sriracha (Pattaya) Ram Hospital in Chiangmai Best choice in Bangkok Best choice Pattaya/Sriracha Best choice Phuket Best choice Chiangmai Best choice any location Other choice - list below Hospital preference

Other hospital preference

Airline   Flight number

Arriving airport   Arrival date and time     

Date of Birth January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year

Height                   Weight

Drug allergies?

Relevant Medical Information (medications?)

Comments or Questions

Would you like information on convenient hotels?     Yes     No

Would you like information on airport and hotel pick up?     Yes     No

Thank you and we look forward to welcoming you to Thailand very soon.