ONLINE MEDICAL REPORT APPLICATION

1 APPLY

2 REQUEST

3 CONSENT

4 PAYMENT

5 SUMMARY

Term & Conditions
1. Online application will be entertain within 3 working days.
2. Application will be processed once the form is completed and payment (if any) is made.
3. Timeline for medical report completion is within 28 working days.
4. Original receipt will be given along once report is completed.
5. IJN reserves the right to amend the terms and conditions without prior notice.
Consent*
I hereby declare and confirm that the information given above is accurate and true.
Consent*
I agree that only the representative's name appear in the authorization letter can claim the report on my behalf.*
Consent*
I hereby release Institut Jantung Negara (IJN) and its employee from all possible legal responsibilities arising out of this content.*

Thank you for submission {Name (Prefix):2.2} {Name (First):2.3} {Name (Middle):2.4} {Name (Last):2.6}
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Patient Information