Dapatkan Temu Janji Anda

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Name/Nama *

Please share your Full Name / Sila tulis nama penuh anda

IC No/Passport No/Birth Certificate No *

Please share your ID Details / Sila berikan maklumat ID anda

Enter your phone number *

Email address *

For Appointment and Record Purpose / Untuk tujuan temu janji dan rekod

Are you a/Adakah anda

• New Patient/Pesakit Baru
• Existing Patient/Pernah datang

Patient Complaint/Masalah Pesakit

Patient main problem to see Doctor / Masalah Utama pesakit datang jumpa doktor

Services needed/Servis yang diperlukan

• Maternity Scan/Scan Mengandung
• Others Scan/Scan lain-lain
• Consultation/Konsultasi
• Dressing/Cuci Luka
• Vaccination/Vaksinasi
• Eye Checkup/Cek Mata
• Ear Checkup/Cek Telinga
• Medical Checkup/Pemeriksaan Perubatan
• Circumcision/Sunat
• Other/Lain-lain

No anda your

Known Medical illness/Penyakit Sedia Ada

• Diabetes/Kencing Manis
• Hypertension/Darah Tinggi
• Heart Problem/Sakit Jantung
• Allergic/Alahan
• Other/Lain-lain

When are you planning your visit?/Bilakah anda ingin datang ke klinik? *

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