Appointment - BNH HOSPITAL

[EN] Appointment /w Doctor

Please complete the form below to request an appointment at BNH Hospital. After you submit the form,
a representative will contact you within 48 hours to review your medical information before an appointment may be offered.

Please note: This form cannot be used for medical emergency or scheduling same-day appointment.

If you have any problem with online appointment please contact our staff

Appointment Information *

I will choose a doctor

Recommend specialist for me

Select a specialty to narrow the list of doctors

Doctor Name *

Please select department *

Appointment Information

Preferred Appointment Date (Option 1) *

please make an appointment at least 2 day

Time (Option 1) *

Preferred Appointment Date (Option 2) *

please make an appointment at least 2 day

Time (Option 2) *

Purpose of Appointment *

Patient Information

Title *

Full Name *

Date of Birth *

Contact Email Address *

Phone number

We will protect your data and privacy. We will offer content or services based on your information. or in matters that we expect you may be interested in
However, I have read and understood very well the Privacy Policy and agree to disclose information to doctors, nurses, staff or personnel of BNH Hospital Related Please tick the box below if you acknowledge this and would like us to continue to contact you.

I consent to the hospital collecting survey data. and process this survey

Agree

Not Agree

I agree that the hospital will contact me to make an offer. information and related services

Agree

Not Agree

Please Verify

If you are human, leave this field blank.