Jen Ai Chang Gung Health International Medical Center Appointment Request Form

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New Patients

Regular Patients

Self-paid COVID-19 Test

To request a Self-paid COVID-19 Test appointment, please enter the information below and press the "Send Appointment Request"
button when you have completed the form or if you prefer, you can fill out the same information in our Google Form.

Please click (here) to download the Application Form for Self-paid COVID-19 Test & send back the completed form.

Patient Information

* indicates a required field

Title

Mr.

Mrs.

Ms.

Dr.

First Name *

Middle Name

Last Name *

Name in Chinese
(on NHI card)

Gender

Male

Female

Marital Status

Single

Married

Divorced

Widowed

Date of Birth *

　(ex. mm/dd/yyyy)

Nationality *

Local Address *

Local Address in Chinese
(on ARC)

City *

Telephone

　(ex. 04-xxxx-xxx )

Mobile Number *

(ex. 09xx-xxx-xxx)

E-mail

　(ex. xxx@xxx.xxx)

Passport Number *

ARC Number *
(if applicable)

Are you applying for new ARC? *

Yes

Appointment Information

Have you been to Jen-Ai Hospital before? *

Yes

If yes, JAH Registration Card Number

Do you have National Health Insurance card? *

Yes

Preferred Date of Appointment *

　(ex. mm/dd/yyyy)

Departure Date

　(ex. mm/dd/yyyy)

Flight No.

Expected date for PCR Report *

PCR - Urgent (Same day, pick-up after 6 PM) – NT$4,500
PCR - Regular (Next day, pick-up after 6 PM) – NT$3,500
Rapid Antigen Test (Same day, pick-up after 1 hour) – NT$1,000

Do you need an interpreter? *

Yes

If yes, what language?

General Comments:

Note:
If you have any questions about your Self-paid COVID-19 Test, please call the
International Medical Center (0963-175-765), Monday ~ Friday, 9 am ~ 5:30 pm.

Please be sure to review your selections carefully before submitting this request. Jen Ai Chang Gung Health International Medical Center looks forward to assisting you and asks that you provide as much information as possible so that we may serve you better when you come in for your appointment.

Please send us the following items: Passport, ARC, NHI card, e-ticket & completed Application Form
for Self-paid COVID-19 Test (preferably in pdf or jpg files) by email to: ipc@mail.jah.org.tw
or if you like, you may upload your documents to our shortened Google Form. Thank you.

Jen-Ai Hospital