Please take your time to fill in the necessary information to complete your request in English only.

Part 1 - Personal Information







Male Female






as above



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Part 2 - Travelling Information


* Please choose date from calendar.

* Please choose date from calendar.







No Yes





Part 3 - Medical Information







Details of Medical Preparations Add more, if there is more than one medication in requested.

Trade Name Quantities Unit Edit Delete

During your proposal stay in Thailand, do you expect to news medical costs requiring further medical treatment or follow up?




Please provide the attachments to complete the process.

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I certify the following ...