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What form needed for Doc's Certificate for Visa Extension?


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Last time I went to get an extension to My 30 day Visa exemption/VoA on Medical grounds I took the letter from the Doctor in English and Thai, but was told that I needed to get another form which they gave me filled in at the hospital.

Does anyone know the official name/number of this form?

I need to get a new one and the hospital dont seem to know what I'm talking about, nor can I get an answer from Chiang Mai Immigration on the phone.

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