TELE-SUPERVISED ART

Application For Tele-supervised ART

Patient’s Full Name as per NRIC/FIN

Patient's NRIC/FIN

Gender

Male

Female

Date Of Birth

Nationality

Local Address

Postal Code

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.)

Thanks for submitting!