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.

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.