Fill Out and Upload Your Medical Form

At Bangkok Health Service, we understand that your medical information is personal and sensitive. This secure page allows you to easily upload your medical forms, reports, or images so we can prepare your treatment plan in advance.

Confidentiality is our highest priority. All information you provide is treated with strict confidentiality and is only shared with the relevant medical professionals involved in your care.

If you have any questions or prefer to send your documents by email, please contact us at info@bangkokhealthservice.com.

Thank you for placing your trust in us. We look forward to assisting you with your treatment in Thailand.

Consultation Type

Surgeon assessment from medical form and pictures (I'm not in Thailand)
Physical consultation (I'm in Thailand)

GENERAL INFORMATION

Patient Name

First

Last

AS APPEARS IN YOUR PASSPORT

Nationality

Age

Date of birth

Gender

Weight (kg)

Height (cm)

Phone

Passport Number:

Upload passport picture

Drag & Drop Files, Choose Files to Upload

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PERSON TO CONTACT IN CASE OF EMERGENCIES

Person or let us be your emergency backup

Family or friends
Bangkok Health Service

SURGERY DETAILS

Planned Date of Surgery

Flying home on (Date)

What procedures do you require?

What results do you expect? (Please be as specific as possible)

Questions to surgeon

MEDICAL CONDITIONS (Please click box if yes)

If you have answered YES to any of the above, please specify

Have you had or do you have any medical conditions not mentioned above?

MEDICAL HISTORY

Have you been hospitalized or received medical care in the past 12 months?

Have you had any surgery before?

Do you have fillers, implants or any metal objects in your body?

Do you have difficulty with healing or scarring?

Do you have any allergies to food, drugs, etc. ?

List all medications you currently take including dosage for each:

List all vitamins or food/nutritional supplements you currently take:

Have you ever taken a MAO inhibitor such as Nardil, Marplan or Parnate?

Have you ever taken an anticoagulant such as Coumadin, Heparin, or a daily Aspirin?

Do you smoke?

Do you drink alcohol?

Any other disabilities or conditions not mentioned above?

Upload medical records / X-rays / MRI Scans

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

If you have any additional information to share, please upload here. Not required.

Medical History Terms & Conditions

By ticking this box, I agree to the data processing terms outlined in the full Terms and Conditions.

Consent to Data Use and Information Sharing

I hereby give my explicit consent for Bangkok Health Service Co., Ltd. to collect, store, process, and share the personal and medical information I have provided in this form for the purpose of evaluating possible treatment options and planning medical or wellness services.

I understand and agree that:

My information may be shared with selected medical professionals, hospitals, clinics, or wellness providers for assessment and treatment planning purposes only.

Bangkok Health Service will treat all data with strict confidentiality and in accordance with applicable data protection laws (including the EU General Data Protection Regulation (GDPR) and the Thai Personal Data Protection Act (PDPA)).

My information will not be sold or used for marketing purposes without my further consent.

I may withdraw my consent at any time by contacting Bangkok Health Service, and I understand that doing so may limit the services they can provide.

By signing below, I confirm that I have read, understood, and agree to the terms stated above.

Patient/Carer/Guardian Signature

Clear Signature

Date