Type your location in the field below and click "Find my address" - then move the pin to correct location manually
Contact person in case of emergency:
Mailings and reminders
Current general health status.
. If applicable & possible, please bring copies of medical files to the intake consultation.
Recent Medical Tests
If yes, please bring the test results to the intake consultation.
While we will keep your personal and medical data strictly confidential, by signing this application form you give us permission to share your information with other medical professionals, medical centers and hospitals if and when we regard this relevant for your treatment.
I affirm that I have answered all the above questions to the best of my knowledge and that the above information is a complete and accurate record of my current health condition including all known medical conditions and other information that may be relevant to my undertaking of the treatments and services provided by the Be Well Medical Center
n.b. you can submit this form on-line or print and bring it with you at the intake consultation. After review with the doctor you can sign the form. Under Thai law, for children under 20 years of age this form needs to be (co) signed by a legal parent