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CONTACT US


Siam Renal Foundation
P.O. Box 27 Banglumphu Bon
15-18 Sip Sam Hang Road, Talhad Yod Sub-District,
Phra Nakorn District, Bangkok, Thailand 10203
Telephone: (+66) 87 353 1689 (24 hours)

 

 
 

Patient Information

Please complete and submit form below,
you will be contacted by a member of our team within 48 hours.


* Name 
 
* Day-time Phone Number 
 
Night-time Phone Number
 
* Email Address 
 
City 
 
* Country 
 
Age 
 
Blood Type 
 
Are you currently on dialysis? 
  Yes   No
Do you currently have any of the following conditions:
High Blood Pressure 
  Yes   No
TB 
  Yes   No
HIV/AIDS 
  Yes   No
Hepatitis 
  Yes   No
Diabetes 
  Yes   No
Cancer 
  Yes   No
Heart or Liver Disease 
  Yes   No
Message 
 
     
* Security Code 
 
Security Code