Moderna Covid-19 Vaccine Survey

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Announcement - “Moderna” the alternative vaccine

Bangkok Hospital Pattaya is looking at the need for alternative vaccine by this survey

Survey respondents must be existing patients of Bangkok Hospital Pattaya.

Please complete the survey using QR code below between 8 – 22 July 2021 only

The vaccination questionnaire is for a survey of numbers only. If we have a progress of the alternative vaccine, we will contact you via the name and phone number you provided.

HN (Hospital Number) *

Example: 02-XX-XXXXXX (Can be found on medicine sachets/ appointment slip/ medical certificate/ receipt or Contact Registration Tel. 0 3890 9100 ext. 5151 at 8.00 am - 4.00 pm. )

First Name *

Do not include a prefix

Last Name *

Gender *

Date of birth *

Please enter as per example 12/31/1999 (M/D/Y)

YYYY

Passport Number *

Please enter without space e.g. PA0305XXXX

Mobile Number *

Example: 089555XXXX

Vaccination service *

I give my consent to the hospital to contact me with confirmation of the vaccination service

Required

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