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Request A Health Screening
Title
*
Mr
Mrs
Ms
Dr
Name
*
Family Name
Given Name
Date of Birth
*
Sex
*
Male
Female
Email
*
Contact Number
*
Health Screening
*
BLOOD PACKAGE 1
BLOOD PACKAGE 2
EXECUTIVE MEDICAL SCREENING MEN
EXECUTIVE MEDICAL SCREENING WOMEN
BACK TO WORK COVID-19 SCREENING
Clinic
*
POLKLINIK PRIMA
POLIKLINIK MEDIPRIMA SRI GOMBAK
KLINIK SARRIMADH
KLINIK FAMILI BUKIT SENTOSA
POLIKLINIK SENTOSA
POLIKLINIK MEDIPRIMA DENAI ALAM
KLINIK SAUJANA
POLIKLINIK DAN PEMBEDAHAN BANDAR
POLIKLINIK MEDIPRIMA CHERAS TRADER SQUARE
Preferred Date
*
Preferred Time
*
:
HH
MM
AM
PM
Is this your first visit?
*
Yes
No
Reason for Visit/Comments
*
In addition to health screening, do you have any other medical concerns you would like to address?
*
Career Form
Name
First
Last
Email
Position
*
MEDICAL OFFICER
GENERAL CLERK CUM DATA ENTRY
NURSE
SOCIAL MEDIA EXECUTIVE
SENIOR BUSINESS DEVELOPMENT
Comments
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Staff/Doctor Name
*
First
Date
Time
:
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MM
AM
PM
Comments
Elaborate more about the incident
Suggestions
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Feedback Form
Polite & Friendy
Nurses/doctor are polite/friendly?
Satisfied
Less Satisfied
Not Satisfied
Waiting TIme
How was the waiting time for registration/doctor/medication
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Not Satisfied
Explanation
How well the nurse/doctor communicate with you.
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Not Satisfied
Comments
Suggestion for better improvement of clinic
Suggestion Form
Comments
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