Jen Ai Chang Gung Health International Medical Center Appointment Request Form

Home > Request Form > Regular Patients

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

First Name *

Last Name *

Name in Chinese
(on NHI card)

Telephone *

- 　(ex. 04-xxxxxxxx or 09-xxxxxxxx)

E-mail *

　(ex. xxx@xxx.xxx)

Appointment Information

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:

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