BIMC Hospital Kuta /

BIMCare Membership

Bimcare Membership (2)

Bimcare Membership (1)

Application Form

BIMCare Membership

Given Name*
Surname*
Email*
Nationality*
Date of Birth*
Sex *
Phone
Mobile
Card Type*
Address

Additional Family Member

Additional Family Member 1
Name
Date of Birth
Sex
Additional Family Member 2
Name
Date of Birth
Sex
upload scanned copy KTP/KITAS/KITAP*
"BIMC Privilege Club is available upon presentation of KTP/KITAS/KITAP or retirement visa"

Get in Touch

We value your inquiry and interest towards our services in BIMC Hospital, therefore please complete this following form and we will respond to you within maximum 48 hours of receiving your request.