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
Mr. Mrs. Ms. Dr.
First Name *
Last Name *
Name in Chinese
(on NHI card)
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 No
If yes, JAH Registration Card Number
Do you have National Health
Insurance card? *
Yes No
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 No
If yes, what language?
General Comments:
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
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e-mail to: ipc@mail.jah.org.tw
Date Modified: 1/17/2022