Manarom Hospital

New Patient Registration

Please fill in the information completely, correctly and truthfully for the benefit of providing appropriate medical services. The information you provide will be used for the purpose of registering for service only and will be kept safely according to the hospital's standards.

Title

First Name

Last Name

Birthday

Nationality

Marital Status

Occupation

Mobile Phone

Current Address

Subdistrict

District

Province

Zipcode

E-Mail

Please enter a valid email address.

History of drug/food allergies

Persons authorized by the hospital to be contacted in case of emergency and should be a family member.

Name-Surname

Relationship

Telephone

Name-Surname

Relationship

Telephone

Name-Surname

Relationship

Telephone

Persons authorized to access medical data

Copied from a person authorized to be contacted by the hospital in case of emergency.

Name-Surname

Relationship

Telephone

Name-Surname

Relationship

Telephone

Name-Surname

Relationship

Telephone

Contact person in case the patient cannot be contacted

Copied from a person authorized to be contacted by the hospital in case of emergency.

Copied from a person who has permission to access medical history data

Name-Surname

Relationship

Telephone

Name-Surname

Relationship

Telephone

Name-Surname

Relationship

Telephone

I have checked the above information and confirm that all information is complete and correct.

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First Name

Last Name

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