Chivawattana - New Subscription

* Required field
Title :
First Name* :
Middle Name :
Last Name* :
Hospital Number (HN) : (if available)
Passport No. / ID No.* :
Date of Birth* :
Mailing Address* :
City* :
State / Province :
Country* :
Zip / Post Code* :
Home No.* :
E-mail Address* :

IN CASE OF EMERGENCY

Contact Person :
Relationship to Patient :
Home Phone No. :
Street Address :
City :
State / Province :
Country :
Zip / Post Code :

Family Members (Including yourself) classified by age
1-15 yrs : person(s)
16-25 yrs : person(s)
26-35 yrs : person(s)
36-45 yrs : person(s)
45-60 yrs : person(s)
More than 60 yrs : person(s)
Type of Card to Apply* :


For payment by money transferred to "Chivawattana" account number 215-0-31318-3 Bangkok Bank, Branch Praram 9, please fax a payment slip to Chivawattana Life Promotion at fax 02-310-3245. You can also contact our staff at tel 02-310-3245 everyday during 7.00 am - 7.00 pm or Contact Center at 1719.


 

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Bangkok Hospital Medical Center, 2 Soi Soonvijai 7, New Petchburi Rd., Bangkok, Thailand 10310 Tel. (+66) 2310-3102