Temporary Member Registration

Temporary Membership

We have initiated a temporary membership for visitors who stay in Hua Hin for a short period but still would like to have access to the full range of our medical services, including phone consultations and house & emergency night calls.

The terms & conditions for this short-term membership are:

The membership will have a maximum duration of 90 days.
A temporary member has access to all medical services during this period at the same terms as full members (terms as published on our website).
The membership fee will be THB 1000 per applicant (no additional charge for spouse and children) and includes up to two free phone consultations during the membership period.
A health-check & intake consultation will not be required for the registration procedure of the temporary membership.
The applicant has to fill in the registration form for temporary members which is available at the clinic and below.
Upon receiving the signed form, a copy of the applicant’s ID, and payment we will confirm the temporary membership for the period indicated.

Member fee is payable by bank transfer to following account:

Bank : Kasikorn Bank
Account name : Be Well Medical Center
Account number : 048-8-089145

REGISTRATION FORM FOR TEMPORARY MEMBERS

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.

Main applicant:

First Name: (required)

Middle Name:

Family Name: (required)

Your Email (required)

Date of Birth (required)

(required) MaleFemale

Nationality

Passport/ ID number:

Expiry date

Address (Thailand) (required)

Pin your Location

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

Find my address

Telephone: (required)

Other members of the family (names, sex and date of birth).

Medical history

Please describe any special medical conditions in your family members that may be important for our medical team to know in case of emergencies during your stay in Hua Hin (e.g. chronic diseases, special medication, allergies, current treatments).

Period in Hua Hin

Arrival: (required)

Departure: (required)

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.

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 our 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

Temporary Member Registration

REGISTRATION FORM FOR TEMPORARY MEMBERS

(maximum period of 90 days)

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