BKFL CLINIC

Patient Registration Form

Personal Information

ID Card / Passport No.*

First Name*

Last Name*

Nickname

Gender*

Date of Birth*

Age

Occupation

Nationality*

Contact Information

Present Address

Sub District

District

Province

Postal Code

Email*

Mobile Phone*

Social Media

Facebook

Instagram

Line ID

TikTok

Emergency & Medical

Contact Person in Case of Emergency*

Emergency Contact Number*

Relationship*

Drug Allergy*

Medical Condition*

Surgical History

Consent & Declaration

I hereby certify that my personal data given to the medical record of BKFL Clinic are true and correct. I also give permission to BKFL Clinic to take my pictures in order to keep them as a record and for medical purposes. If any incorrect data are found, I will be solely responsible for any resulting damages or consequences.

* I agree to the terms and conditions and consent to the collection and use of my personal data as described above.

Date

12 August 2026

Personal Information

Contact Information

Emergency & Medical

Preferred Communication

Surgical History

Consent & Declaration