Jen Ai Chang Gung Health International Medical Center Appointment Request Form

Home > Request Form

New Patients

Regular Patients

Self-paid COVID-19 Test

To request a medical appointment, please enter the information below and press the "Send Appointment Request" button when you have
completed the form. If you prefer to make an appointment by phone, please call the International Medical Center (0963-175-765) and
we will make the appointment for you.

Patient Information

* indicates a required field

Title

Mr.

Mrs.

Ms.

Dr.

First 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-xxxxxxxx or 09-xxxxxxxx)

E-mail *

　(ex. xxx@xxx.xxx)

Passport Number *

NHI Card Number

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)

Reason for appointment and/or primary complaint: *

Specialty / Department you would like to be seen in:

Preferred doctor you would like to see:

Do you need an interpreter? *

Yes

If yes, what language?

General Comments:

Note:

If there is an urgency regarding your problem, please call the International Medical Center
(0963-175-765) and go directly to the Emergency Room.

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 ask that you
provide as much information as possible so that we may serve you better when you come in for your
appointment.

Jen Ai Chang Gung Health