Registration for Outpatient Appointment

International Medical Service Center
Registration for Outpatient Appointment

Service Details

  • Charge rate:It costs NT$1500 for each outpatient appointment, including registration fee NT$300 and consultation fee NT$1200. Drugs, special examinations, laboratories, treatment fees will be charged separately.
  • Our service requires a reservation in advance. Please contact us as early as one week before your arrival, so we can properly arrange your medical procedures.
  • A case officer will be assigned to accompany you and give you any assistance during the whole process.
  • We can arrange a special outpatient appointment with the physician of your choice. Otherwise, the physician who is available on the day of your appointment will see you.
  • To expedite your outpatient procedures, we can schedule your examinations or laboratories according to your attending physician's prescription prior to your scheduled appointment with the said physician.
  • We offer a separate service lane for international patients to avoid long queues.

General Information

  • Date of application: (ex:yyyy-mm-dd)
  • Identity of applicant:
    patient
    patient's friend or family
    colleague from Tzu Chi Overseas Foundation
    colleague from Taiwan Buddhist Tzu Chi Foundation
    others (please specify) :
     
  • From where did you learn about the services of the international medical service center:
    Tzu Chi Overseas Foundation
    Taiwan Buddhist Tzu Chi Foundation
    Tzu Chi volunteer
    Da Ai TV
    friend or family
    internet search
    others (please specify) :
     
  • Mode of communication:
    app (line, we chat, telegram..)
    email
    phone
    in person
  • Previous medical record in Hualien Tzu Chi Hospital:
    none
    cannot recall
    outpatient
    inpatient
  • Medical record number :    (please write "forgot" if you don't remember)

Personal Information

  • Surname: First name:
  • Gender: male  female
  • Medical record number (or passport number):
  • Date of birth:  (ex:yyyy-mm-dd)
  • Age: 
  • Address in country of origin:
  • Contact home phone number (+ country code and area code):
  • Cell phone (+ country code):
  • Email:

Outpatient appointment requirement

  • Diagnosis:
  • Consulting physician:
     Physician of choice:  
     recommended by International Medical Service Center
  • Mode of outpatient service:
     General outpatient appointment
     Special outpatient appointment
  • Please indicate the duration of your stay in Taiwan:

Disease History

  • Hypertension
    yes   no
  • Cardiovascular disease
    yes   no
  • Stroke
    yes   no
  • Diabetes
    yes   no
  • Kidney disease
    yes   no
  • Asthma or lung disease
    yes   no
  • Joint replacement
    yes   no
  • Cancer
    yes   no
    Please specify:
  • Blood disease
    yes   no
  • Arthritis
    yes   no
  • Epilepsy
    yes   no
  • Liver disease or hepatitis
    yes   no
  • Eye disease
    yes   no
  • Endocrine disease
    yes   no
  • Gastrointestinal disease
    yes   no
  • Others, please specify
    yes   no
    Please specify:

Other Information

  • Do you have any previous surgery?
    no   yes ,please specify the type of surgical procedure or provide operative records: 
  • Is there anyone in your family with similar disease?
    no   yes ,please specify: 
  • Do you have allergies to any medicine or food?
    no   yes ,please specify: 
  • Are you taking any medicine now?
    no   yes ,please provide the picture of medicine or prescription

Attachments

  • Cardiovascular System:
    CT   ECG   PCI surgery   Treadmill   Ultrasound/2D Echography  Medical Summary
    Others (please specify)
     
  • Respiratory System:
    X-ray   CT   Bronchoscopy   Pulmonary Function Test   Ultrasound   Medical Summary
    Others (please specify)
     
  • Breast:
    Ultrasound   Mammography   Biopsy   X-ray   Medical Summary
    Others (please specify)
     
  • Endocrine System:
    Medical Summary   Medical Laboratory
    Others (please specify)
     
  • Nervous System:
    MRI   CT   EMG   Angiography   Medical Summary
    Others (please specify)
     
  • Skeletal System:
    MRI   CT   X-ray   BMD Test   Medical Summary
    Others (please specify)
     
  • Urinary & Reproductive System:
    Cystoscopy   Cystography   Video-Urodynamics   Ultrasound   Hysteroscopy   Biopsy   Medical Summary
    Others (please specify)
     
  • Digestive System:
    Ultrasound   Oesophago-Gastro-Duodenoscopy   Colonoscopy   Biopsy   Medical Summary
    Others (please specify)
     
  • Cancer:
    Biopsy   Medical Summary
    Others (please specify)
     

Medical Enquiry

  • treatment plan   disease diagnosis   medical care   others
  • Please specify your enquiry:
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花蓮慈濟醫院 國際醫學中心 International Medical Service Center