top of page
Application For Tele-supervised ART
Patient’s Full Name as per NRIC/FIN
Date Of Birth
Email (Please provide a valid email address if MC or memo is required)
Mobile Number (Please provide a valid mobile number if MC or memo is required)
Drug Allergies, if any
Emergency Contact Name
Emergency Contact Number
Emergency Contact Relationship
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 patient requiring telemedicine does not have any of the red flag symptoms listed and that a parent/guardian/caregiver will be in accompaniment if the patient is a minor under the age of 16 or does not have agency.
(Click here to view the terms & conditions again.)
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 am aware that the telemedicine service is only available between the hours as stated on PanCare Medical’s website. If I am submitting this form outside of the stated telemedicine service operating hours, I understand that I will only be contacted by PanCare Medical at the next available operating slot and no refund(s) will be provided.
(Click here to view telemedicine operating hours again.)
Proceed to Payment
Thanks for submitting!
Chronic Disease Management
CHAS & Medisave
bottom of page