Chia-Yi Christian Hospital International Medical Center

Online Appointment

First Name

Last Name

Sex

Male Female

Date of Birth

AD Year Month Day

Nationality

Address

Zip

Telephone

Country Code Region

Fax

Country Code Region

E-mail

Passport Number

Language

Chinese English Others(specify)

Appointment Information

Have You Been to Chia-Yi Christian Hospital?

Yes No

If yes, what is your CYCH Registration Number

Preferred Date of Appointment

Reason for Appointment

Hypertension (high blood pressure)　 Neurologic (nerve) disorder
Heart disease Alcoholism, drug addiction
Drug allergy(specify)
Cancer(specify)　　　

Past Medical History

Diabetes　　　 Kidney disease
Depression Thyroid problems
Tuberculosis (TB)　 Others (specify) 　　

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