BANGKOK HOSPITAL, BANGKOK
Registration form for COVID-19 Vaccination Campaign of The Embassy of France, Thailand.
Location of Vaccination : BANGKOK
Name
*
First Name
Family Name
Title
*
Please Select
Mr.
Ms.
Mrs.
Gender
*
Please Select
Male
Female
Not specified
Date of Birth
*
-
Day
-
Month
Year
*This vaccination campaign is eligible for French citizen aged 55 and over only.
Age
*
*This vaccination campaign is eligible for French citizen aged 55 and over only.
Nationality
*
Passport Number
*
Email address
*
example@example.com
Mobile Number
*
Please enter a valid phone number.
Address in Thailand
*
Street Address
Street Address Line 2
City
Province
Postal / Zip Code
Appointment Date and Time
*
Have you ever registered at the selected hospital?
*
Yes
No
If yes, please provide your Hospital Number (H.N)
00-00-000000
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform