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ONLINE REQUEST FOR APPOINTMENT
* Compulsory field
** At least one out of the 3 fields
Patient's Details:
Medical Record No.
(for IJN's Existing patients only)
Patient Name
*
Sex
*
Male
Female
DOB
*
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New IC No.
**
(eg. 601112026329)
Old IC No./ Birth Cert.
**
(eg. A9865248)
Passport No.
**
(for international patients only)
Citizenship
Foreigner - Expatriate
Foreigner - Medical Tourism
Foreigner - Visitor
Malaysian
Permanent Resident
Contact No. 1
*
Contact No. 2
Contact No.(Fax)
Email
*
Referral Details:
Name of referring doctor
Name of referring hospital
Appointment Details:
Preferred appointment Date
1st choice date
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Year
2012
2013
AM
PM
2nd choice date
Day
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Year
2012
2013
AM
PM
Prefer IJN's doctor’s name
Additional notes/brief summary of health condition
Terms of use
By submitting this appointment form, I hereby agree that : 1. Making an appointment on this website with IJN is for the sole purpose of scheduling only. IJN, its employees, any physician or clinician with whom an appointment has been made by use of this website has not agreed to provide the undersigned with any medical advice, diagnostic or therapeutic procedure until the undersigned has registered in person at IJN. 2. All information provided by me is true and accurate and I further agree that IJN shall not be held responsible for any indirect information in connection with the information provided herein. 3. Any dispute or claim (including injury claims) related to health care services which I receive from IJN which is not resolved by mutual agreement is subject to Malaysian law and the exclusive jurisdiction of the appropriate court in Malaysia.
I agree to the terms stated above.
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