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Online Pre-Registration (Child)

Outpatient registration consent form

Please fill out this form accurately and completely. Be assured that all information submitted through this online pre-registration form will be treated by Samitivej Hospital as part of your confidential patient record.

1
General Info
2
Parent
Info
3
Pediatric New
Patient Info
4
Siblings

*Required

LOCATION*
LOCATION*
First Name*
First Name*
Last Name*
Last Name*
Gender*
Gender*
Citizenship*
Citizenship*
Religion*
Religion*
Country*
Country*
Current Address*
Current Address*
EMAIL*
EMAIL*

Do you have a different permanent address?*