SHIN KONG WU HO-SU MEMORIAL HOSPITAL
International Medical Tour Appointment Request Form
Your Personal Information*Name: / (First Name/Middle Initial/Last Name)
*Date of Birth: / (mm/dd/yyyy)
*Gender: / □Female □Male
*Passport Number: / *Citizenship：
ARC Number(if applicable):
Address: / (Number/Street/Apartment/City/State/Zip code/Country)
Contact Information: / (Country code/Area code/Phone number)
Home：
Office：
*Cell：
*E-mail:
Medical Tour Appointment Information
*Have you visitedSKH before? / □Yes □No; If yes, the reason for visit
*Duration you are planning to stay in Taiwan for this tour: / The most possible duration：From to (mm/dd/yy)
Secondarypossible duration：From to (mm/dd/yy)
*Expecting Treatment/ Health Examination: / □ Cardiovascular InterventionTreatment and Surgical Operation
□ Infertility Treatment □Joint Replacement
□Half-day Physical Examination □CT □MRI □PET
□Other
*Any particular sites/places you would like to visit: / □Yes; Where：
□No; Please arrange the tour for me.
If you select “Yes”, we will design a customized tour for you. If you select “No”, we will offer you our luxury tour packages for you to make the choice.
*Do you have previous medical reports, films (X-ray, MRI, CT scan), and pathology slides? / □Yes □No
If yes, please send all applicable information via courier to Shin Kong Wu Ho-SuMemorialHospital. Mailing address is located at the bottom of this form. Thank you.
*Other Visitors/Family Member Information: / (Name/Relationship)
(If there is more than one member planning to join this tour with you, please have each of them to complete the attached form and submit it along with yours form. Thank you.)
*Indicates a required field.
1. Please check to be sure that all information in this form is correct before submitting.
2. Fax completed forms to +886-2-28329292 or e-mail to. We will make every effort to process your request as quickly as possible. Thank you.
3. Please send your medical reports, films to: No.95, Wenchang Rd., Shilin District, TaipeiCity 111, Taiwan (R.O.C.)
For Other Visitors/Family Members
Your Personal Information*Name: / (First Name/Middle Initial/Last Name)
*Date of Birth: / (mm/dd/yy)
*Gender: / □ Female □ Male
*Passport Number: / *Citizenship：
ARC Number(If applicable):
Address: / (Number/Street/Apartment/City/State/Zip code/Country)
Contact Information: / (Country code/Area code/Phone number)
Home：
Office：
*Cell：
*E-mail:
*Indicates a required field.
1. You may copy this form if there is more than one member going to join this tour. Please note that all participants are asked to complete this form.
2. Please check to be sure that all information in this form is correct before submitting.
3. Fax all necessary completed forms to 886-2-28329292 or e-mail to.. We will make every effort to process your request as quickly as possible. Thank you.