Please fill out this form with accurate and complete information.
Assured that all information submitted in this online pre-registration form will be treated by The Samitivej Hospital as part of your confidential patient record.
My Account I want to register
for :
You will need the following information to complete this form :
- Your insurance card (if you do not have insurance, see below)
- Referral letters form other physicians (only if applicable)
- Name and phone number of an emergency contact.
- Employment information
Please bring the following documents to your first appointment at
Samitivej Hospital :
- Your ID card or passport
- Your insurance card (only if applicable)
- Referral letters form other physicians (only if applicable)
- Employment information
Please note :
- This online form is not intended for appointment requests or for a services scheduled within 24 hours.
- Please submit your online pre-registration at least 48 hours in advance of your hospital stay or visit to allow adequate time for processing your information.