Pre-Appointment Form

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PRE-APPOINTMENT FORM

Please fill out your details below to book an appointment.

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    JohorKedahKelantanMelakaNegeri SembilanPahangPerakPerlisPulau PinangSabahSarawakSelangorTerengganuKuala LumpurLabuanPutrajaya

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    Self PayingPersonal InsuranceCompanyGovernment (Pensioner)Government (Employee)

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    Self PayingPersonal InsuranceCompany

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    YesNo

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    *Appointment is subject to the availability of the specialist*

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    *This column is applicable to all payment categories
    CardiologistPaediatric CardiologyConsultant Cardiothoracic SurgeonsPulmonologistEndocrinologistConsultant Vascular SurgeonNephrologistNot Sure






    Referral letter *

    Referral letter (if any)

    MyKad/MyKid & Birth Certificate (if below 12 years old) / Passport (for Foreign Patient) *

    Valid Guarantee Letter/Pension Card/Letter from JPA for Parents of Pensioner (for Federal Pensioner)/Retiree's Parents' Affidavit (for Government Agencies *subject to payor) / College letter for child above 18 and below 21 yrs.) *

    Valid Visa (if any)

    Valid Visa *

    Test Result (if any)

    Test Result *

    (if Any) OKU card and Medical Expert's Report and Certification Form for the Retiree's Disabled Dependent (Approval from Medical Specialist from Government Hospital) / Certification Letter from Department Head


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    Thank you for submitting your
    Pre-Appointment Form

    Our team has received your details and will contact you shortly to confirm your appointment.
    We value your input and would love your feedback to help us enhance your experience.