E-Consent Application

Bangkok Hospital Phuket respects the privacy of our customers’ personal information. In order to comply with the Personal Data Protection Act (PDPA) B.E. 2562 (2019), please provide your personal information and consent to receive our medical information and updates about our services and promotions via our communication channels. Section 1: Personal Information

Title *

Name *

Family Name *

Date of birth *

Gender *

Mobile Phone Number *

Please enter a valid Mobile number.

Please enter 10 digit mobile phone number without spaces or dashes. (Thai mobile phone number only)

E-mail

Please enter a valid email address.

(e.g. [email protected])

Address in Thailand