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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 *
Allowed special character (, # / -)
Billing Name
Billing Address
Allowed special character (, # / -)
Email Address *
Contact No *
Consent Form *
FORM-MRO-003 Patient Particulars and Consent for Release of Medical Information to Third Party and send together with this request.
Selected file:
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.