TELECONSULT (NON-ART)

Application For Teleconsult (non-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)

Symptom(s)/reason(s) for consultation

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.)

Please select the current timeslot correctly. All amounts are inclusive of 7% GST.

Teleconsult, Weekday (non-public holiday), 8am to 5pm - S$16.05

Teleconsult, Weekday (non-public holiday), after 5pm to 9pm - S$21.40

Teleconsult, Weekend and/or public holiday, 8am to 9pm - S$26.75

Thanks for submitting!