นัดตรวจเยี่ยมผู้ป่วย

1. Patient Information

This information is used to identify and contact the patient.

Nationality *

Thai National ID *

Please enter a 13-digit Thai National ID.

Patient First Name *

Patient Last Name *

Nickname (Optional)

Gender *

Date of Birth *

Birth Month *

Year of birth *

Marital Status

How did you hear about Yuenyen?

Referrer (Optional)

Enter the referrer’s name or leave blank.

2. Relative / Contact Person Information

Please provide information of a relative or contact person.

First Name

Last Name

Nickname

Age

Gender

Relationship to Patient

Other Relationship

Primary Phone Number

Secondary Phone Number

WhatsApp number

Example: +66813043322

LINE ID

Display Name

Please provide LINE information if you would like our team to contact you via LINE.

3. Care Location Address

Please provide the address where our team can visit or provide services.

3. Care Location Address

Province

District / Amphure

Subdistrict / Tambon

Postal Code

Google Maps Link

Paste the map link to help the medical team travel to the location more conveniently.

4. Medical Conditions / Disease / Symptoms

This information helps our care team prepare appropriate treatment and support.

Disease Group

Select the existing medical condition.

Other Diseases (Optional)

Other Symptoms (Optional)

Hospital 1

HN / Patient ID

Hospital Name

Hospital 2 (Optional)

HN / Patient ID

Hospital Name

Healthcare Coverage

Patient’s healthcare coverage or medical benefit.

Regular Medications

Enter medication names or leave blank if none.

Allergy History / Food / Others

Specify allergens and symptoms.

5. Previous Treatment History

Please provide only relevant information to help our team better understand the patient’s condition.

Yuenyen Service Registration Form