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Pre-Registration Ear Examination MIDE 2025
Thank you for your interest in undergoing ear examination / ear scope with our ENT specialist. Kindly fill up the details below.
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1. Name (As per NRIC) *
2. Your Identification Number (NRIC) *
3. Phone Number *
4. Email Address *
5. Are you a diver? *
6. Do you have any pre-existing health conditions? *
7. If your answer is YES in Q6, what is the pre-existing health conditions?
8.  Did you undergo an ear examination with us at MIDE 2024 last year?   *
When is your last medical checkup?
Write N/A if not applicable
 *
Preferred Date and Time Slots for Ear Examination / Scope
*The slot is first come first served basis
 *
Assunta Hospital – Personal Data Protection Notice
Details of  Assunta Hospital's Personal Data Protection Notice is available at
https://www.assunta.com.my/personal-data-protection-notice/
By submitting this form, you hereby agree with the terms and conditions and give your consent to Assunta Hospital to provide you with event updates, latest promotion and marketing materials in the future.
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Required
Assunta Hospital is committed to ensuring that all personal information handled by us will be processed accordingly to legally compliant standards of data protection and data security of the company (https://www.assunta.com.my/personal-data-protection-notice/) I have read the Personal Data Protection Act, Malaysia 2010 (PDPA) provided by Assunta Hospital.
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Thank You!
See you soon!
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