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  • Registration for children

Registration for children

Please fill in the information below and press 'Submit'.

    Sex
    Required
    Name(English)
    Required
    Date of Birth
    Required


    Phone Number
    Required

    Email
    Required
    Insurance
    Required
    Address
    Required
    Emergency Contact
    Required



    Do you have any chronic diseases?
    Required

    Do you take any medicine regulrarly?
    Required

    Have you ever got surgery or admit before?
    Required


    Do you have any allergy for medicines?
    Required


    Do you have any allergy for food?
    Required


    Do you have any other allergy?
    Required


    Has your kid ever had unusual reaction after taking medicine?
    Required

    Please select the disease your kid has suffered before and fill out the age of it.
    Optional
    　years old
    　years old
    　years old
    　years old
    　years old
    　years old
    Are there any other severe diseases which you kid has ever had?
    Optional
    Gestational age
    Required
    　weeks
    Weight when birth
    Required
    　gram
    Please select the following.
    Required
    Asphyzia experience
    Required
    Does your kid has juandice when birth?
    Required
    Do you want to have Free vaccine consultation today?
    Required

    Depending on the level of congestion, it may take some time before we can assist you with your vaccine consultation. Thank you for your understanding in advance.

    How did you come to know us?
    Required
    If you need to fill following info on receipt, please fill them out.
    Optional


    Inquiry
    Optional
    If you have the following photos, please attach them.
    Passport
    Optional

    Insurance
    Optional

    Access

    Access

    Address：139, RQ49 Mall 4th Floor, Unit 541,
    Soi Sukhumvit 49(Klang),
    Klongton-Nua, Wattana,
    Bangkok 10110