Health Screening Registration Form
Note: For advanced booking
Fill up this form
We offer advanced booking and registration services. Kindly fill up the pre-registration form for advance registration purpose.
Email address *
Personal Detail
Please provide us with 3 working days for confirmation of your appointment booking. Bring along original Passport or IC on the screening day.
Medical Check-up Date *
MM (Month) DD (Day) YYYY (Year) for calendar selection, kindly using Google Chrome web browser.
MM
/
DD
/
YYYY
Patient's Name (Follow exact name in NRIC or exact name in Passport) *
Your answer
Tel No / HP No *
Your answer
NRIC / Passport No: *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Age *
Your answer
Gender *
Marital Status *
Race *
Your answer
Religion *
Your answer
Nationality *
Address *
Your answer
Poscode *
Your answer
Occupation *
Your answer
Payment Mode *
Corporate Name
If select "Corporate" please fill in corporate name for reference.
Your answer
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