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Registration

BE WELL MEDICAL CENTER

MEMBER’S REGISTRATION FORM

Note:
You may prefer to postpone your visit for blood tests and the initial consultation. It is possible to register for membership and receive full membership benefits while the routine assessments can be completed at a later date.
If you prefer, you can print the form and bring it with you or complete the form during the intake consultation. Download Registration Form Here!

The questions marked with (required) have to be answered to file for registration. Please fill in the other information as far as possible/relevant.

    MaleFemale

    Type your location in the field below and click "Find my address" - then move the pin to correct location manually

    Find my address

    Contact person in case of emergency:

    Mailings and reminders

    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)

    Medical history

    Current general health status.

    . If applicable & possible, please bring copies of medical files to the intake consultation.

    Medical History

    Allergies

    Do you have any allergies? E.g. from food, medicines, insect bites, etc.

    Vaccinations

    Family history

    Is there a history of any serious illness or disease in your close family (e.g. diabetes, asthma, heart disease, cancer):

    Recent Medical Tests

    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.

    Insurance data

    Do you have medical health insurance?

    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

    Be Well
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