ilovepdf_merged (5)

หนังสือรับรองการเสียชีวิต Date: ………………………………….…..Time:………………....….…
(Medical Certificate of Death) HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..

วนั ท่ี...............................................
(Date)

เน่ืองด้วย (นาย / นาง / นางสาว / อนื่ ๆ โปรดระบ)ุ .......................................................................................................................

(Mr. / Ms. / Mrs. / Others please indicate)

ได้ถงึ แกก่ รรมด้วยโรค................................................................................................................................................................................

(Had passed away the cause of death appears to be)

เม่ือวนั ท.่ี ...............................................................เวลา...........................น. ณ โรงพยาบาลธนบรุ ี บารุงเมอื ง

(On date) (Time) (at Thonburi Bamrungmuang Hospital)

โดยหนงั สอื ฉบบั นี ้ญาตขิ องผ้ถู ึงแก่กรรมมคี วามประสงค์จะนาศพไปบาเพ็ญกศุ ลที.่ .......................................................................
(The body will be taken by relatives for further religious ritual at)
……………………………………………………………………………………………………………………………………………
ขอรับรองวา่ เป็ นความจริง
(I, here, certify that the above statement is true and correct)

................................................................
(……………………………………………)

แพทย์ผ้ใู ห้การรักษา
(Physician)

FM-MSO-011-00

General Medical Certificate Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:

Allergies: MD Code

ตรวจเม่อื วันที่ (Date of Examination)........................................................................................... เวลา (Time) ...............................

ผลการตรวจ (Findings) ...................................................................................................................................................................……….
..........................................................................................................................................................................................................................
..........................................................................................................................................................................................................................
..........................................................................................................................................................................................................................
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ความเหน็ (Summary) ....................................................................................................................................................................................
............................................................................................................................................................................................................................

ขอรับรองว่าขอ้ ความข้างตน้ เป็ นความจริง (The above statements are true.)

(ลงช่อื ) ................................................................ แพทยผ์ ตู้ รวจ

Physician's Signature

ใบประกอบวชิ าชพี เวชกรรม เลขที่ .................................

License No.

(ลงช่อื ) .............................................................. ผรู้ บั การตรวจ

Patient's Signature

หมายเหตุ (Remark) ........................................................................................................................................................................................
............................................................................................................................................................................................................................
............................................................................................................................................................................................................................

สาหรบั ผปู้ ่ วย (For Patient) สาหรบั วางบลิ บริษทั คู่สัญญา (For Contract Company)

FM-MSO-005-00

Date:………….………..….
Ref. No.: …………..….…..

MEDICAL CERTIFICATE

To whom it may concern,

This letter is to certify that I,……………………………………………………………….., M.D. with Medical License No.
……………….have examined Mr./Mrs./Miss/Master…………………………………., a/an Emirati/Omani/Kuwaiti/Qatari/Sudanese
patient with Passport No…………and Hospital Number (HN) ………………………….on……………………………..who has been
treated at Thonburi Bamrungmuang Hospital as an Outpatient / Inpatient on / during / between…………….…until………………….

With Chief Complaints of:

Diagnosis/Diagnoses:
1.
2.
3

Treatment/Investigation:
- Medication
- X-ray
- Investigation (Imaging Studies/Laboratory Tests)
- Dressing
- Physical Therapy
- Procedure
- Surgery ……………………………………………………………………………………………………………….
- Others…………………………………………………………………………………………………………………

Recommendations:
- Patient came for examination on………………………
- Patient needs to rest for…………….day(s)
From ………………..….until……………………….
- Advice(s)………………………………………………………………………………………………………………

ATTENDING PHYSICIAN’S NAME

Medical license No. xxxxx
Specialty

Thonburi Bamrungmuang Hospital Page 1
611 Bamrungmuang Rd., Klong Mahanak Sub-District, Pomprabsattruphai District, Bangkok, Thailand 10110. Tel.: +662 220-7999
www.thonburibamrungmuang.com FM-MSO-001-00

Arabic Coordination Center (ACC)
611 Bamrungmuang Rd., Klong Mahanak, Pomprapsattruphai,Bangkok Thailand 10100 Tel.+662-220-3884-5

Date: ____________________
Ref. CTL0001/2019

To whom it may concern,
This letter is to certify that I, , M.D. Medical License No._________

Have examined _______________________________, _______ Patient with a passport No. _________________
and a Hospital No. ____________on ___________________who has been treated at Thonburi Bamrungmuang
Hospital as an OPD/IPD between ________________until___________________.
With diagnosis of:

-
-
-
-
The Patient is suggested for a respite for__________ which is between _______________ to

___________________ because of the state of illness.
The Patient is also recommended for ___________________________________________________
____________________________________________________________________________________

Best Regards,
_________________________
JARANPA SAMRITWILAS, M.D.
Medical License No. 40485
General Surgeon and wound Specialist

FM-MSO-014-00(Eng.)

Arabic Coordination Center (ACC)
611 Bamrungmuang Rd., Klong Mahanak, Pomprapsattruphai,Bangkok Thailand 10100 Tel.+662-220-3884-5

FM-MSO-014-00(Eng.)

Date: …….………………..
Ref. No.: …………………

MEDICAL CERTIFICATE

To whom it may concern,

This letter is to certify that I,……………………………………………………………….., M.D. with Medical License No.
……………….have examined Mr./Mrs./Miss/Master…………………………………., a/an Emirati/Omani/Kuwaiti/Qatari/Sudanese
patient with Passport No…………and Hospital Number (HN) ………………………….on……………………………..who has been
treated at Thonburi Bamrungmuang Hospital as an Outpatient / Inpatient on / during / between………….…until…………………

With diagnosis/diagnoses of:
1.
2.
3.
4.
5.

▪ The patient has been treated with ………………………………………………………..
▪ The patient has been under the care of specialist for co-morbidities treatment
▪ The patient is planned to be discharged on ……………………………………….
▪ Regarding above-mentioned condition, the patient could not go to work / study and is suggested for SICK LEAVE

of ……………………….. day(s) from ……………………… until………………………

ATTENDING PHYSICIAN’S NAME, M.D.

Medical license No. xxxxx
Specialty

Thonburi Bamrungmuang Hospital Page 1
611 Bamrungmuang Rd., Klong Mahanak Sub-District, Pomprabsattruphai District, Bangkok, Thailand 10110. Tel.: +662 220-7999
www.thonburibamrungmuang.com FM-MSO-023-00

Arabic Coordination Center (ACC)

611 Bamrungmuang Rd., Klong Mahanak, Pomprapsattruphai,Bangkok Thailand 10100 Tel.+662-022-3884-5

Medical Certificate for Visa Extension

ข้าพเจ้า (This is certify that I,) ...............................................................................................................................................................................................

ใบอนญุ าตประกอบวิชาชีพเวชกรรมเลขท่ี (Medical license number)........................................................................................................................................

สถานทตี่ รวจ(Place of Examination) :โรงพยาบาลธนบรุ ี บารุงเมอื ง 611 ถนน บารุงเมอื ง แขวง คลองมหานาค เขต ป้อมปราบศตั รูพา่ ย กรุงเทพมหานคร 10100

(Thonburi Bamrungmuang Hospital 611 Bamrungmuang Road khongmahanak pomprabsattruphay Bangkok 10100)

ได้ตรวจร่างกาย (I have examined)...................................................................................…………………… Age: …........Y. HN: …………………….……

สญั ชาต(ิ Nationality)………………………………..…... หนงั สือเดนิ ทางเลขท่ี(Passport Number)………………………………………………………….……….

โดยมารับการตรวจ(As) [ ] คนไข้นอก (Outpatient) [ ] คนไข้ใน (Inpatient)

อาการ กรุณาระบุอาการท่ีนามาเป็นภาษาไทย (Please indicate symptom (s) in Thai) ............................................................................................................
...............................................................................................................................................................................................................................................
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ผลการตรวจวนิ ิจฉัยโรค กรุณาระบุเป็นภาษาไทย(Please indicate diagnosis in Thai) ............................................................................................................
...............................................................................................................................................................................................................................................
การรักษา / การตรวจวนิ ิจฉยั (Treatment / Investigation)

[ ] ให้ยา( Medication) ……………………………………………………………………………………………………………………………………. ….
[ ] เอ็กซเรย์ ( X-ray) ……………………………………………………………………………………………………………………………………………
[ ] การตรวจวเิ คราะห(์ Laboratory)…………………………………………………………………………………………………………………………..
[ ] ทาแผล ( Wound dressing)………………………………………………………………………………………………………………………………..
[ ] กายภาพบาบดั ( Physical therapy) ………………………………………………………………………………………………………………………

[ ] ทาหตั ถการ ( Procedure, please indicate) …………………………………………………………………………………………………………….
[ ] ผา่ ตดั ระบุ ( Surgery, please indicate) …………………………………………………………………………………………………………………
[ ] อน่ื ๆ ( Others) ………………………………………………………………………………………………………………………………………………

ความคิดเหน็ ของแพทย์ (Physician’s Recommendations) : ผ้ปู ่วยจาเป็นต้องได้รับการรักษาต่อเน่ือง(Patient needs medical treatment for)

[ ] 15วนั (Days ) [ ]21 วนั (Days) [ ]30 วนั (Days) [ ]45 วนั (Days) [ ]60วนั (Days) [ ]90วนั (Days)

**จงึ เป็นอปุ สรรคต่อการเดนิ ทาง (Not fit to travel)**

ทนั้ นีจ้ งึ ขอความอนเุ คราะหจ์ ากทางสานกั งานตรวจคนเข้าเมอื งในการตอ่ วซี า่ ให้แกผ่ ้ปู ่วยและญาติ/ผ้ตู ิดตาม ดงั นี ้ (ถ้าหากมี)

(We would like to request the kind cooperation from The Immigration Bureau to extend the Visa for the patient and relative/escort person as follows. (If any))

1. ชือ่ (Name).................................................................................................. สญั ชาต(ิ Nationality)...........................................................

หนังสือเดนิ ทางเลขที(่ Passport Number)......................................................ความสมั พนั ธ์(Relationship)................................................

2. ชือ่ (Name).................................................................................................. สญั ชาติ(Nationality)...........................................................

หนงั สอื เดนิ ทางเลขท(่ี Passport Number)......................................................ความสมั พนั ธ์(Relationship)................................................

3. ชื่อ(Name).................................................................................................. สญั ชาติ(Nationality)...........................................................

หนงั สอื เดนิ ทางเลขท(่ี Passport Number)......................................................ความสมั พนั ธ์(Relationship)................................................

ลงช่ือ(Physician’s Signature)........................................................แพทย์ผ้ตู รวจ (M.D)
(…………….………………………….)

Date: ……. / …................../…………………

FM-MSO-021-00

FIT FOR TRAVEL MEDICAL CERTIFICATE

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Patient Name: MR./MRS./MASTER/MISS

Hospital Number: Room: XXX, WARD XX

Age: XX YEARS OLD Gender: MALE/FEMALE

Date of Birth: Nationality:

Date of Admission:

Attending Physician: XXXXXXXX, M.D.

Report Reference No: MRR. XXXXXX-X Date of Report: XXth MAY 2019

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To whom it may concern:

This is to certify that the above-named patient has been examined and treated at our hospital as an:

 Outpatient  Inpatient during…………………………………………………………………………………………..……….………….

Diagnosis

1.

2.

3.

4.

Travel Recommendation (Please  check in the box where applicable):

Opinion about Air Travel:  Fit to Fly
Fit to Travel as:
Mode of Transportation:  Not Fit to Fly due to………………………………………………………………….…………………….…

 Normal Passenger  Family Escort/Non-Medical Escort

 Medical Escort:  Doctor  Nurse  Doctor and Nurse

 Commercial Airlines  Air Ambulance (Private Jet)  Others…………………….

Travel Class:  Economy Class  Business Class  First Class  Stretcher

Wheelchair:  WCHR (Wheelchair Ramp) WCHS (Wheelchair Steps)  WCHC (Wheelchair Cabin)

Oxygen Supply: Yes……………LPM  Standby  Continuous

Special Needs: ……………………………………………………………………………………………………………………..……………………….…

Physician’s Signature……………………………………………….. Medical License No. ………….. Telephone: +662-220-7999
I understand the risk(s) involved in air travel and accept full responsibility for myself.

……………………………… …………………………………. ….………………………
Patient’s Signature Full Name Date

……………………………… .………………………………. ..…………………………
Other Legally Authorization ID Number/ Passport Number Relationship to Patient

……………………………. ………………………………… ………………………….
Language used in Translation Translator Witness

(If required)

Note:
1. The final decision on whether the patient is allowed to board the plane or not mainly relies on the concerned airline(s).

2. This certificate is valid for 7 days from the date of issuance. (Valid until…………………..)

Thonburi Bamrungmuang Hospital Page 1
611 Bamrungmuang Rd., Klong Mahanak Sub-District, Pomprabsattruphai District, Bangkok, Thailand 10110. Tel.: +662 220-7999
www.thonburibamrungmuang.com FM-MSO-009-00

Thonburi Bamrungmuang Hospital Co.,Ltd.
611 Bamrungmuang Rd., Klong Mahanak,
Pomprabsattruphai, Bankkok 10100
Tel. +66 2220 7999

Medical Certificate

Book No. ………………... No. ………….…………..

Part 1 for the patient who requests for the medical fitness certificate
I, Mr./Mrs./Miss .........................................................................................................................................................................................................................,
residing at address ....................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................,

national identification number □-□□□□-□□□□□-□□-□,

would like to request for the medical fitness certificate. Below is my health history.

1. chronic health condition/disease □ No □ Yes (please specify)....................................................................................................................

2. accident and operation □ No □ Yes (please specify)....................................................................................................................

3. hospital admission □ No □ Yes (please specify)....................................................................................................................

4. other important history .............................................................................................................................................................................................

Signature .................................................... date ......................month.....................year......................

If the patient is a child who cannot certify his/own health history, the guardian may sign on this document on behalf of the child.

Part 2 for the physician

Place of examination ...........................................................................................................................date ......................month......................year....................

(1) I, Dr. ....................................................................................................................................., medical license No. ................................................................,

location of medical practice ........................................................................................................................................................................................................,

examined Mr./Mrs./Miss ...............................................................................................................................................................................................................

on date ....................month..........................year...................... Details are as follows:

weight .............. kg, height ............... cm, blood pressure ................................ mmHg, pulse .........................beats per minute

general health condition □ normal □ abnormal (please specify) ........................................................................................................................................

I certify that the person is fit to work and free from disability with no symptom of psychosis, delusion, mental retardation, drug addiction, and

alcohol use disorder. Also, there is no sign and symptom of the following diseases:

(1) leprosy at the infective stage or the stage with apparent symptoms that may be disgusted by society;

(2) tuberculosis at the dangerous period;

(3) elephantiasis at the stage with apparent symptoms that may be disgusted by society and

(4) other (if any) ..........................................................................................................................................................................................................

......................................................................................................................................................................................................................................................

(2) Physician's opinion and recommendation ..............................................................................................................................................................................

......................................................................................................................................................................................................................................................

......................................................................................................................................................................................................................................................

signature .................................................................Physician
Note: (1) must be the physician who owns the medical license;

(2) describe the patient's fitness. This certificate will be valid for one month since the date of examination;
(3) this certificate is the result of initial examination.
This form is approved by resolution of The Medical Council of Thailand meeting No. 4/2018 on 19 April 2018.

FM-MSO-015-06(Eng)

Thonburi Bamrungmuang Hospital Co.,Ltd.
611 Bamrungmuang Rd., Klong Mahanak,
Pomprabsattruphai, Bankkok 10100
Tel. +66 2220 7999

แบบ สณ.๑๑

ใบรับรองแพทย์

สถานพยาบาล (๑)………………..................………
วนั ที่…………เดอื น…………………พ.ศ…………

ข้าพเจ้า นายแพทย์/แพทย์หญิง (๒)……………………………………………………...........…….............……………….....……
แพทย์ปริญญา เป็ นแพทย์ทไ่ี ด้ขนึ ้ ทะเบียนและรับใบอนญุ าตให้เป็ นผ้ปู ระกอบโรคศลิ ปะแผนปัจจบุ นั ชนั้ หนงึ่ สาขาเวชกรรม
ใบอนญุ าตประกอบวชิ าชีพเวชกรรม เลขที่……………………………ตาแหนง่ หน้าท่ี………………...................……………………….……
ประจาโรงพยาบาล…………….............……………ได้ทาการตรวจร่างกาย (นาย/นาง/น.ส.)…………………...…............…………………
อาย…ุ ……….ปี เมื่อวนั ท่ี………….เดอื น…………........……….พ.ศ……………………. แล้ว ปรากฏวา่

(นาย/นาง/น.ส.) .................................................................................................................................................................…
ไมเ่ ป็ นผ้มู รี ่างกายทพุ พลภาพจนไมส่ ามารถปฏบิ ตั ิหน้าทไ่ี ด้ ไร้ความสามารถ หรือ จิตฟ่ันเฟือนไมส่ มประกอบและปราศจากโรคเหลา่ นี ้

(๑) วณั โรค
(๒) อหวิ าตกโรค
(๓) ไข้รากสาดน้อย (ไทฟอยด์)
(๔) โรคบิด
(๕) ไข้สกุ ใส
(๖) โรคคางทมู
(๗) โรคเรือ้ น
(๘) โรคผิวหนงั ที่นา่ รังเกียจ
(๙) โรคตบั อกั เสบทีเ่ กดิ จากไวรัส
(๑๐) โรคอน่ื ๆ …………………….................................................................................................................…………….......
สรุปความเหน็ และข้อแนะนาของแพทย์ (๓)……………………………………………………………………………………………
………………………………………………………………………………..………………………………………………………..……….…
………………………………………………………………………………..……………………………………………………………………
………………………………………………………………………………..……………………………………………………………………

ลงชื่อ ...................................................................แพทย์ผ้ตู รวจร่างกาย
(.............................................................)

หมายเหตุ (๑) ให้ประทบั ตราสถานพยาบาลพร้อมทงั้ ระบทุ ่อี ยู่
(๒) ต้องเป็ นแพทย์ซง่ึ ได้ขนึ ้ ทะเบยี นรับใบอนญุ าตประกอบวิชาชพี เวชกรรม
(๓) ให้แสดงวา่ เป็นผ้มู รี ่างกายสมบรู ณ์เพียงใด ใบรับรองแพทย์ฉบบั นี ้ให้ใช้ได้ ๒๑ เดอื น นบั แตว่ นั ทต่ี รวจร่างกาย

FM-MSO-022-06

Medical Transportation Report Date: Time:
HN: Room:
Name:
Date of Birth: Gender:
Physician: Age:
MD Code
Allergies:

Request Information
Symptom/Purpose(include all appointments today) …..……………………………………………………………………………………..…….

Level of consciousness Alert Confused Drowsy Stuporous Comatose

Triage level Resuscitation Emergency Urgent Semi-urgent Non Urgent

Address Requesting person

Tel. Tel.

Nurse Contact date Contact time

Patient Assessment

1. Neurological

LOC Alert Confuse Drowsy Stuporous Comatose

Motorpower Arm Right Normal Power Mild Weakness Severe Weakness

Left Normal Power Mild Weakness Severe Weakness

Leg Right Normal Power Mild Weakness Severe Weakness

Left Normal Power Mild Weakness Severe Weakness

Pupil Right Size …………..mm Reaction Sluggish Non-Reaction Other ……………… N/A

Left Size ………...…..mm Reaction Sluggish Non-Reaction Other ……………… N/A

GCS: Eye……..……... Verbal…….....…… Motor………...…... Other ………………………………………………………………...

Los Angeles Prehospital Stroke Screen (LAPSS) Yes No, Specify…………..……… N/A

LAPSS criteria Yes No Unknown Exam Equal Right weak Left weak

1. Age > 45 years Facial smile Droop Droop

2. History of seizures or epilepsy absent Hand grip Weak Weak

3. Symptom duration < 24 hours No grip No grip

4. Patient is not wheelchair bound Arm strength Drifts down Drifts down

or bedridden at baseline Falls rapidly Falls rapidly

5. Blood glucose between 60-400 mg/dl Based on exam, Patient has only unilateral weakness Yes No

2. Cardiovascular EKG Rhythm NSR Abnormal N/A

3. Respiratory Room air Cannula…………...…L/min Mask with bag…………….…L/min Ambu bag Ventilator

Tracheostomy tube…………...…… Collar mask …………...….…L/min Other ………………………

4. Gastrointestinal Normal Abnormal………………………………………………………….

5. Genitourinary Normal Abnormal………………………………………………………….

6. Drain NG tube No Yes, Number ………..……… Foley’s cath No Yes, Number ………..…...……

Gastrostomy tube No Yes, Number …………..…… ICD No Yes, Number ………….....……

Other………………………………………………………………………………………

7. Wound Abrasion Laceration Avulsion Burn Other ………………….......…...…….….. N/A

8. Muscle and Skeletal ……………………………………………………………………………………………………………. N/A

9. Immediate Needs No Suspected Airborne Isolation Precaution Other …………………….……………

Accompanying person Nurse 1.) …………………. 2.) ……………………
Driver 1.)…………. Physician……………………………………………………. Non RN ……………….. Relative ………………….
Driver 2.)…………. Emergency Medical Technician-Basic……………………

Physician or staff’s Signature ……………..………………….……… Employee ID ……………… Date ………………. Time …………

FM-ERD-004-00

FIT FOR TRAVEL MEDICAL CERTIFICATE

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Patient Name: MR./MRS./MASTER/MISS

Hospital Number: Room: XXX, WARD XX

Age: XX YEARS OLD Gender: MALE/FEMALE

Date of Birth: Nationality:

Date of Admission:

Attending Physician: XXXXXXXX, M.D.

Report Reference No: MRR. XXXXXX-X Date of Report: XXth MAY 2019

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To whom it may concern:

This is to certify that the above-named patient has been examined and treated at our hospital as an:

 Outpatient  Inpatient during…………………………………………………………………………………………..……….………….

Diagnosis

1.

2.

3.

4.

Travel Recommendation (Please  check in the box where applicable):

Opinion about Air Travel:  Fit to Fly
Fit to Travel as:
Mode of Transportation:  Not Fit to Fly due to………………………………………………………………….…………………….…

 Normal Passenger  Family Escort/Non-Medical Escort

 Medical Escort:  Doctor  Nurse  Doctor and Nurse

 Commercial Airlines  Air Ambulance (Private Jet)  Others…………………….

Travel Class:  Economy Class  Business Class  First Class  Stretcher

Wheelchair:  WCHR (Wheelchair Ramp) WCHS (Wheelchair Steps)  WCHC (Wheelchair Cabin)

Oxygen Supply: Yes……………LPM  Standby  Continuous

Special Needs: ……………………………………………………………………………………………………………………..……………………….…

Physician’s Signature……………………………………………….. Medical License No. ………….. Telephone: +662-220-7999
I understand the risk(s) involved in air travel and accept full responsibility for myself.

……………………………… …………………………………. ….………………………
Patient’s Signature Full Name Date

……………………………… .………………………………. ..…………………………
Other Legally Authorization ID Number/ Passport Number Relationship to Patient

……………………………. ………………………………… ………………………….
Language used in Translation Translator Witness

(If required)

Note:
1. The final decision on whether the patient is allowed to board the plane or not mainly relies on the concerned airline(s).

2. This certificate is valid for 7 days from the date of issuance. (Valid until…………………..)

Thonburi Bamrungmuang Hospital Page 1
611 Bamrungmuang Rd., Klong Mahanak Sub-District, Pomprabsattruphai District, Bangkok, Thailand 10110. Tel.: +662 220-7999
www.thonburibamrungmuang.com FM-MSO-009-00

หนังสือรับรองการเสียชีวิต Date: ………………………………….…..Time:………………....….…
(Medical Certificate of Death) HN.:……………………………….….……Room:………………..........
Name:……………………..…………...…Gender:………..……..…….
Date of Birth:………………………..……Age:………….………..……
Physician:…………………..……...……..MD Code:………..…..….…
Allergies:………………………………….………………………..……..

วนั ท่ี...............................................
(Date)

เน่ืองด้วย (นาย / นาง / นางสาว / อนื่ ๆ โปรดระบ)ุ .......................................................................................................................

(Mr. / Ms. / Mrs. / Others please indicate)

ได้ถงึ แกก่ รรมด้วยโรค................................................................................................................................................................................

(Had passed away the cause of death appears to be)

เม่ือวนั ท.่ี ...............................................................เวลา...........................น. ณ โรงพยาบาลธนบรุ ี บารุงเมอื ง

(On date) (Time) (at Thonburi Bamrungmuang Hospital)

โดยหนงั สอื ฉบบั นี ้ญาตขิ องผ้ถู ึงแก่กรรมมคี วามประสงค์จะนาศพไปบาเพ็ญกศุ ลที.่ .......................................................................
(The body will be taken by relatives for further religious ritual at)
……………………………………………………………………………………………………………………………………………
ขอรับรองวา่ เป็ นความจริง
(I, here, certify that the above statement is true and correct)

................................................................
(……………………………………………)

แพทย์ผ้ใู ห้การรักษา
(Physician)

FM-MSO-011-00

611 Bamrungmuang Rd., Klong Mahanak, Pomprapsattruphai,Bangkok Thailand 10100 Tel.+662-220-7999
________________________________________________________________________________________

Embalming Certificate

Date : ……………………………………..

This is to certified that the body of ( Mr. / Mrs./ Miss) :……………………………………..……………
HN :………………………… Age : …………….….. Nationality : ………………….…………..……………………………….
Caused of Death : ………………………………………………………...…..…….. On : ……………………Time : ……...…

Requested by ( Mr. / Mrs./ Miss) :………………………………….……………………… Age : …………
Address ……………………………………………………………………………………………………….……………..…………
Passport / UD card No : ………………………..……. Relationship with patient : …………………………….……………..…

Signature………………………………….(Nurse of Duty)
(…………………..……………………….)

Signature…………………………….…....(Relative)
(…………………..……………………….)

Signature…………………………….…... (Embalmer)
(…………………..……………………….)

Remark : The body of the above mentioned patient was embalmed on.................................. Time : .............................

_______________________________________________________________________________________________
Interpreter's Statement

I have given a………………………..………….. language translation of the Embalming Certificate
explained to patient’s representative.
Name of Interpreter…………………………………….……….……Interpreter’s Signature……………………..……………...

FM-ICU-005-00