Contact person in case of emergency:
Name Relationship to you: Emergency contact Tel number: Emergency contact Email:
Members will receive regular updates concerning medical information and developments at our center. Reminders for check-ups, vaccinations etc. will also be sent via email. I consent to being contacted by Be Well MC for above purposes.(required)
Current general health status.
Please list any ongoing illness that you have. Please list any medicines that you take (and doses): Are you currently, or were you recently, under review by a medical specialist? Please list the illness and name of the hospital/specialist.
. If applicable & possible, please bring copies of medical files to the intake consultation.
Please list any previous significant medical events (diseases, accidents, hospitalization) and indicate if they are still giving you problems.
Do you have any allergies? E.g. from food, medicines, insect bites, etc.
If yes, please specify: If you have a vaccination record book/card please bring it with you to the consultation, or list your vaccines and the dates received (eg Rabies, Tetanus, Hepatitis A/B, Shingles/Zoster, Pneumonia, TB)
Is there a history of any serious illness or disease in your close family (e.g. diabetes, asthma, heart disease, cancer):
If yes, please specify:
Have you undergone any tests (e.g. blood, ECG, scans, or other) in the last six months?
If yes, please bring the test results to the intake consultation.
Do you have medical health insurance?
Please provide the name of your insurance company and the type of policy
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.
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
Membership fee is payable in person or by bank transfer to the following account:
Bank : Kasikorn Bank
Account name : Be Well Medical Center Account number : 048-8-089145
Please read and click the box to confirm before sending! 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