iHEAL Medical Centre
COVID-19 Screening Registration Form
Registration Type:
Individual
Organization
Organization Name:
Full name as per passport/IC:
IC/Passport no: (without - or spaces)
Date of birth: (eg.31-12-2020)
Gender:
Male
Female
Nationality:
Mobile no:
Email address:
Email address 2 (Optional):
Current address: (including Address, Postcode, City)
Appointment:
PCR
Antibody
Antigen
Date of appointment: (eg.31-12-2020)
Mon - Friday : 9am - 5pm | Sat : 9am - 1pm | Sun & PH : Closed
Symptoms:
Fever
Colds
Cough
Sore Throat
Difficulty breathing or shortness of breath
Myalagia (Muscle pain)
Headache
Diarrhoea
Travel history within the past 14 days
Undergone an examination at any health facility before
None of the above
Is the result required to be sent to a Person-In-Charge:
Required
Name of PIC:
Contact No of PIC:
Email Address of PIC:
Mode of Payment:
On-Site Payment
Online Bank-In
Guarantee Letter
How did you hear about us?:
MyCovit.com
PCA21
MYCIND
MYCWRK
Others
Upload Payment Receipt