Inquiry Rep Webform
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レフェラルオフィスに問い合わせる
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)
の付いた全ての欄は入力必須です。
国をお選びください
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:
Please Select
Australia
Bahrain
Bangladesh
Cambodia
Chad
China
Ethiopia
Hong Kong
Indonesia
Kenya
Kuwait
Laos
Mongolia
Myanmar
Nepal
Oman
Pakistan
Qatar
Russia
Sudan
UAE
Ukraine
Vietnam
Virtual RO
Please select country of Bumrungrad office
この問い合わせは
*
:
患者本人
友人・親戚
患者様の情報
お名前
:
(パスポートまたは他の身分証明書と同じ表記)
名字
:
生年月日
*
:
Invalid date
性別
*
:
男性
女性
居住国
*
:
Please select
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegowina
Botswana
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Cocos (Keeling) Islands
Colombia
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Cote D'ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
European Union
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Holy See (VATICAN City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (ISLAMIC Republic Of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Non-spec Asia Pas Location
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Vincent and The Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia (SLOVAK Republic)
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Pierre and Miquelon
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan; Republic of China (ROC)
Tajikistan
Tanzania United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (BRITISH)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Yemen
Zambia
Zimbabwe
*
国籍
:
バムルンラードにおかかりになったことはありますか?
:
いいえ
はい
診察券番号
:
お問合せ内容
*
:
Please enter a subject
ご質問内容
*
:
私の情報
E メール・アドレス
*
:
- Please enter your email
- Email format is invalid
もう一度E メール・アドレスをタイプしてください。
*
:
- Please retype your email
- Email and retyped email do not match
お名前
*
:
- Please enter your first name
(パスポートまたは他の身分証明書と同じ表記)
名字
*
:
- Please enter your last name
生年月日
*
:
Invalid date
性別
*
:
男性
女性
Please select My's gender
居住国
*
:
Please select
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegowina
Botswana
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Cocos (Keeling) Islands
Colombia
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Cote D'ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
European Union
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Holy See (VATICAN City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (ISLAMIC Republic Of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Non-spec Asia Pas Location
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Vincent and The Grenadines
Samoa
San Marino
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia (SLOVAK Republic)
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Pierre and Miquelon
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan; Republic of China (ROC)
Tajikistan
Tanzania United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands (BRITISH)
Virgin Islands (U.S.)
Wallis and Futuna Islands
Yemen
Zambia
Zimbabwe
*
Please select country
国籍
:
Please select
Afghan
Albanian
Algerian
American
Andorran
Angolan
Antiguan, Barbudan
Argentinian
Argentinian
Armenian
Aruban
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Basotho
Belgian
Belizian
Belorussian
Beninese
Bermudian, Bermudan
Bhutanese
Bolivian
Bosnian
Botswanan
Brazilian
British
Bruneian
Bulgarian
Burkinese
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Caymanian
Central African
Chadian
Channel Islands
Chilean
Chinese
Colombian
Comorian
Congolese
Congolese
Costa Rican
Croatian
Cuban
Cypriot
Czech
Danish
Djiboutian
Dominican
Dominican
Dutch
Dutch Antillean
Ecuadorean
Egyptian
Emirati, Emirian
English
Equatorial Guinean, Equatoguinean
Eritrean
Estonian
Ethiopian
Faroese
Fijian
Finnish
French
French Polynesian
Gabonese
Gambian
Georgian
German
Ghanaian
Gibraltar
Greek
Greenlandic
Grenadian
Guamanian
Guatemalan
Guinean
Guinean
Guinean
Guyanese
Haitian
Honduran
Hong Kong, Hongkongese
Hungarian
Icelandic
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakh
Kenyan
Kiribati
Kosovar, Kosovan
Kuwaiti
Kyrgyzstani, Kyrgyz, Kirgiz, Kirghiz
Laotian
Latvian
Lebanese
Liberian
Libyan
Liechtenstein
Lithuanian
Luxembourg
Macanese, Chinese
Macedonian
Madagascan
Mahoran
Malawian
Malaysian
Maldivian
Malian
Maltese
Manx
Marshallese
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monacan
Mongolian
Montenegrin
Moroccan
Mozambican
Myanmar
Namibian
Nepalese
New Caledonian
New Zealand
Nicaraguan
Nigerian
Nigerien
North Korean
Northern Marianan
Norwegian
Omani
Pakistani
Palauan
Panamanian
Paraguayan
Peruvian
Philippine
Polish
Portuguese
Puerto Rican
Qatari
Romanian
Russian
Rwandan
Sahraw, Sahrawian, Sahraouian
Salvadorean
Sammarinese
Samoan
São Toméan
Saudi Arabian
Scottish
Senegalese
Serbian
Seychellois
Sierra Leonian
Singaporean
Slovak
Slovenian
Solomon Island
Somali
South African
South Korean
Spanish
Sri Lankan
Sudanese
Surinamese
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Togolese
Tongan
Trinidadian, Tobagonian
Tunisian
Turkish
Turkoman
Turks and Caicos Islands
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbek
Vanuatuan
Venezuelan
Vietnamese
Virgin Island
Welsh
Western Samoan
Yemeni
Yugoslav
Zaïrean
Zambian
Zimbabwean
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はい
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Response Time
: During this time, Bumrungrad will reply within 48 hours. Pricing requests may take longer depending on doctor availability and case complexity.
To complete the form, please click "I agree to the terms" before clicking “Send inquiry to Hospital”
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