APPLICATION FOR HOSPITAL
OUT-PATIENT SERVICES

Name of Patient:   Date of Birth:
*   *
Address:   Occupation:
*   *
   
   
Email:    
*    
     
Services required (state which clinic)  
 Clinic
     
Did the patient previously attend this hospital as an out-patent or an in-patient ?
If YES please give particulars   YES NO
     
I here by apply for services for    
Myself Spouse Child
     
For referral, please enter the details of your recommending Doctor below
Doctor's Name
Doctor's Address
     

I declare that the information submitted by me on this form is correct and to the best of my knowledge.  I agree that the Patient Service may make any inquiries that they think fit for the purposes of considering this application and I further agree to report, forthwith, any change in circumstance which may render me and my dependants ineligible.

Do not use this form for emergencies, urgent appointments or services you need today or tomorrow. If you have an urgent request for a service please contact:

Kasemrad Hospital Prachachuen

Tel. (662) 910-1600 Ext.1906

Please Note:  To help in processing your request, the information on this form will be stored in electronic format.

 

  
     
     
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