Appointment-Alternative

Resource:

Name (First..Middle..Last):

Phone:

Email:

Age(Yr)

Gender

Male

Female

Date of Birth (DD/MM/YY)

Nationality

Passport Number

For foreigners; please bring the photocopy of your passport with you

Address

Have you ever visited our clinic?

Yes
No, this will be my first time
No, but I have just registered online
	*

Your Hospital Number (HN)

For traveler who has visited our clinic before

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