New Appointment Form 2 UAT

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APPOINTMENT FORM

Please fill out our Appointment Form below to book an appointment.

* All field is mandatory

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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