<%@LANGUAGE="JAVASCRIPT" CODEPAGE="65001"%> Bangkok Hospital Samui | Samui Hospital | International Hospital Private, Medical Tourism,Koh Samui, Bangkok, Thailand
 
 
 
 
 
 
 
samui
  Appointment
 
 

Bangkok Hospital Samui encourages you to request an appointment. If you need to request an appointment for your relatives, please complete this form and state that in 'comments'. Our customer support will contact you accordingly.

 
All fields marked with an asterisk (*) are mandatory
 
   
Your Appointment Information :  
HN (Hospital Number)  :  If you know
Your Name * :
 
Surname * :
Gender :
Nationality :
Date of Birth : Day Month Year
Passport No./ID * :
  Specialty * :
 Preferred appointment time * : Day Month Year
Time * :
Special request * :
   
Patient Contact Details :  
E-mail * :
Tel (Home) * :
Tel (Mobile) * :
Present Address or Hotel name (in Thailand) :
 
Please enter code shown below. * :
   
 
 
 
 
 
Bangkok Hospital Samui © 2009
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Bangkok Hospital Samui 57 Moo 3, Thaweerat Phakdee Road, Bophut, Koh Samui , Suratthani 84320
Tel:+66 7742 9500  Fax. +66 7742 9540