SHIN KONG WU HO-SU MEMORIAL HOSPITAL
International Medical Tour Appointment Request Form
Your Personal Information
*Name:
(First Name/Middle Initial/Last Name)
*Date of Birth:
(mm/dd/yyyy)
□ Female
*Gender:
□ Male
*Passport Number:
*Citizenship：
ARC Number(if applicable):
(Number/Street/Apartment/City/State/Zip code/Country)
Address:
(Country code/Area code/Phone number)
Contact Information:
Home：
Office：
*Cell：
*E-mail:
Medical Tour Appointment Information
*Have you visited
SKH before?
*Duration you are
planning to stay in
Taiwan for this tour:
□ Yes □ No; If yes, the reason for visit
The most possible duration：From
Secondary possible duration：From
to
to
(mm/dd/yy)
(mm/dd/yy)
□ Cardiovascular Intervention Treatment and Surgical Operation
*Expecting
Treatment/ Health
Examination:
□ Infertility Treatment □ Joint Replacement
□ Half-day Physical Examination □ CT □ MRI □ PET
□ Other
*Any particular
sites/places you
would like to visit:
*Do you have
previous medical
reports, films (X-ray,
MRI, CT scan), and
pathology slides?
*Other
Visitors/Family
Member Information:
□ Yes; Where：
□ No; Please arrange the tour for me.
If you select “Yes”, we will design a customized tour for you. If you select
“No”, we will offer you our luxury tour packages for you to make the choice.
□ Yes □ No
If yes, please send all applicable information via courier to Shin Kong Wu Ho-Su
Memorial Hospital. Mailing address is located at the bottom of this form. Thank you.
(Name/Relationship)
(If there is more than one member planning to join this tour with you, please have each
of them to complete the attached form and submit it along with yours form. Thank you.)
*Indicates a required field.
1. Please check to be sure that all information in this form is correct before submitting.
2. Fax completed forms to +886-2-28329292 or e-mail to A000956@ms.skh.org.tw. We will make every effort to process
your request as quickly as possible. Thank you.
3. Please send your medical reports, films to: No.95, Wenchang Rd., Shilin District, Taipei City 111, Taiwan (R.O.C.)
SHIN KONG WU HO-SU MEMORIAL HOSPITAL
For Other Visitors/Family Members
Your Personal Information
*Name:
(First Name/Middle Initial/Last Name)
*Date of Birth:
*Gender:
(mm/dd/yy)
□ Female
□ Male
*Citizenship：
*Passport Number:
ARC Number(If applicable):
(Number/Street/Apartment/City/State/Zip code/Country)
Address:
(Country code/Area code/Phone number)
Contact Information:
Home：
Office：
*Cell：
*E-mail:
*Indicates a required field.
1. You may copy this form if there is more than one member going to join this tour. Please note that all participants
are asked to complete this form.
2. Please check to be sure that all information in this form is correct before submitting.
3. Fax all necessary completed forms to 886-2-28329292 or e-mail to A008626@ms.skh.org.tw.. We will make
every effort to process your request as quickly as possible. Thank you.