SELF-ADMINISTERED ART

Application For Self-Administered ART For Certifications

Patient’s Full Name as per NRIC/FIN

Patient's NRIC/FIN

Gender

Male

Female

Date Of Birth

Nationality

Local Address

Postal Code

Mobile Number

ART Video Upload

Upload File

I confirm that I have read and agree to the terms & conditions shown on the pop-up box on this page. I confirm that the Supervised ART Subject does not have any of the red flag symptoms listed nor any emergency conditions requiring immediate medical care, aid or attention and is neither a minor nor a person without agency.(Click here to view the terms & conditions again.)

I confirm that the video uploaded fulfils all conditions specified in the terms & conditions.

I consent to the collection, use and/or disclosing of my personal data for the purpose of provision of telemedicine and related services. I agree to be contacted by PanCare Medical via SMS, phone call, WhatsApp, email, Zoom and/or any other mode of tele-communication as is necessary for the provision of telemedicine and related services.

I agree that PanCare Medical is not obliged to provide any refunds if the video is rejected for any reason(s) including, but not limited to limitations to the conditions set out on the pop-up box on this page and/or it is assessed that the ART result is positive.(Click here to view the terms & conditions again.)

Thanks for submitting!