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Health Deliver

Patient Details

First Name*

Last Name*

Contact Number / Email*

Hospital Number*

Date of Birth*

Passport / ID No. *

Country of Residency *

Nationality *

Normal Appointment

Medical Enquiry

Medication Refill

Appointment Details

Preferred Appointment Date/Time *

Preferred Doctor/Specialty *

Purpose of Appointment *

Specific Concern / Request procedure / Interest *

Available investigation / Result

(Attach the document)

Request for interpreter ( Specify the language ) *

Payment Method

Insurance

(Please attach front and back page of an insurance card)

Self-pay

Yes

No

Enquiry Details

Chief Complaint or Diagnosis *

Current condition/symptom *

History of Present Illness *

Medications, Allergies (drug, food, etc.) *

Updated Investigations

(Laboratories/imaging studies, e.g. x-ray, CT, MRI, biopsy result, etc.)

Source of information (relative, referral office, etc.)*

Specific concern / request procedure / interest*

Updated Medical Summary Report

(If possible not older than 2 months, typed-written and in English language, 6 International calendar dates)

Please specify whether the patient is in the hospital or not.

Yes

No

Medication Refill / Medical supply

Primary Doctor's name *

Update the condition after finishing the medication *

Name of the medicine / medical supply *

Quantity *

How to collect the medications (Pick up at Bumrungrad or shipping)*

The address in details with contact number (In case of shipping)

Refill requests are only ELIGIBLE if you have not missed more than ONE year of follow-up with our physician. In case of lost follow- up more than ONE year, we do recommend the patient/relatives appoint with our physician in person or Tele-consultation for consideration.

For International shipping

Please contact your local customs authorities and DHL for the local regulations and other details before starting the process because all the medicines that have been shipped from our hospital can't be returned back to our hospital.

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