Medical Consultation Request

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Are you a former patient at Bangkok Hospital Medical Center (BMC)?
Please specify your Hospital Number (HN) : If available.
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First Name * :
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Last Name * :
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Date of birth * :
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E-mail * :
Mobile / Phone :
Present Illness * :
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Surgery/ procedures required (if known) :
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Bangkok Hospital Medical Center, 2 Soi Soonvijai 7, New Petchburi Rd., Bangkok, Thailand 10310 Tel. (+66) 2310-3102