Make an Appointment BY filling up this form ASA INTERNATIONAL HEALTH SERVICES will conect you directly to The International Patient Services Centre at the Sunshine Hospitals so that they can  thoroughly assess your medical records before you arrive. An appointment specialist will assist you with appointments, laboratory tests, diagnostic tests, hospital admissions and surgical procedures.

 

Please fill in the details below to book an appointment right now. Appointment date requested should be at least 2 working days from the day you submit this.

Contact Information:(required)
Your Name	:
Address	:
Telephone	:
Email	:
Patient Information
Date of Birth	:
Gender	:	Male      Female
Medical Problem (Reason for your inquiry)	:
Service Requested (Please check all that apply)	:	Second Opinion   Treatment  Diagnostic Tests  Complete Physical Exam  Other :
Transportation Information (Please check all that apply)	:	Yes  travel with a companion, guardian or assistant  need special dietary arrangements (if yes,describe   )  need special care arrangements (if yes,describe     )  need transportation to and from airport
Referring Physician Name	:
Telephone No.	:

Phone No.*Mobile:

Country Code	Mobile No.

Facsimile:Email:If you are not the patient...Patient Name:Relationship to Patient: