FPH Medical Request

Please complete all sections. If:

• You are below 21 years old, you are required to obtain the consent of your parents or legal guardian.

• You are requesting on behalf of patient, please fill up the attached FORM-MRO-003 Patient Particulars and Consent for Release of Medical Information to Third Party and send together with this request.

• The person you are applying the medical report for has passed away, please fill up the attached FORM-MRO-003A Consent Letter of Undertaking for Deceased / Mentally Incompetent Patient together with the required documents(s) stated therein with this request.

Requestor Particulars

Request Type *

SelfOn behalf of patient (Additional documents required)

Requestor Name *

Requestor NRIC/Passport Number *

Address *

Allowed special character (, # / -)

Billing Name

Billing Address

Allowed special character (, # / -)

Email Address *

Contact No *

On behalf of Patient Particulars

Patient Name *

Patient NRIC/Passport Number *

FORM-MRO-003 Patient Particulars and Consent for Release of Medical Information to Third Party and send together with this request.

Selected file:

The person you are applying the medical report for has passed away, please fill up the attached FORM-MRO-003A Consent Letter of Undertaking for Deceased / Mentally Incompetent Patient together with the required documents(s) stated therein with this request.

Selected file:

Document of Request

Date

AdmissionDischarge

Requested Document (Please tick accordingly) *

Requestor Remarks

Acknowledgement

By submitting this request, I acknowledge and accept that:

1. A quotation will be sent to me to confirm my request and for my acceptance and that I will not be able to make any amendments after my acceptance.

2. FPH will send me (via email) an invoice within [5] working days after my confirmation of quotation and a receipt within [5] working days after clearance of payment;

3. FPH will only process my request upon receipt and clearance of payment and should be ready within 10 working days upon clearance of payment;

4. All payments made are non-refundable;

5. All my personal data stated herein is complete, true and accurate. Any inaccuracies or incompleteness may in result in a delay in the processing of this request; and

6. I give my consent to Farrer Park Hospital Pte. Ltd. to collect and process my personal data stated herein for the purposes of processing the abovementioned request. I may refer to its website for details of its data protection practices and policies.

Request for Medical Records

Address: 1 Farrer Park Station Road, #02-01 Connexion, Singapore 217562

Contact no: +65 6363 1818

Email Address: [email protected]

Please complete all sections. If:

• You are below 21 years old, you are required to obtain the consent of your parents or legal guardian.

• You are requesting on behalf of patient, please fill up the attached FORM-MRO-003 Patient Particulars and Consent for Release of Medical Information to Third Party and send together with this request.

• The person you are applying the medical report for has passed away, please fill up the attached FORM-MRO-003A Consent Letter of Undertaking for Deceased / Mentally Incompetent Patient together with the required documents(s) stated therein with this request.

Requestor Particulars

Request Type *

Requestor Name *

Requestor NRIC/Passport Number *

Address *

Billing Name

Billing Address

Email Address *

Contact No *

On behalf of Patient Particulars

Patient Name *

Patient NRIC/Passport Number *

Selected file:

Selected file:

Document of Request

Date

Requested Document (Please tick accordingly) *

Selected file:

Document format:

Mode of delivery:

Softcopy

Requestor Remarks

Acknowledgement

1. A quotation will be sent to me to confirm my request and for my acceptance and that I will not be able to make any amendments after my acceptance.

2. FPH will send me (via email) an invoice within [5] working days after my confirmation of quotation and a receipt within [5] working days after clearance of payment;

3. FPH will only process my request upon receipt and clearance of payment and should be ready within 10 working days upon clearance of payment;

4. All payments made are non-refundable;

5. All my personal data stated herein is complete, true and accurate. Any inaccuracies or incompleteness may in result in a delay in the processing of this request; and

6. I give my consent to Farrer Park Hospital Pte. Ltd. to collect and process my personal data stated herein for the purposes of processing the abovementioned request. I may refer to its website for details of its data protection practices and policies.