Request an Appointment

You can request for an appointment by filling up this form.

Please allow 24 to 72 hours (business days) for us to respond to your appointment request.


Patient information



Patient's name *
(as in NRIC/Passport)


Document type * 


Patient's NRIC /
Passport No / FIN *


Date of birth
(dd/mm/yyyy) *


Gender * 



Referral information

Private charges apply for the following referrals made through: 

  1. Choice of doctor by name
  2. GP and Private Hospital
  3. Self referrals
  4. Private patients of Govt/Restructured Hospitals


Referred by * 


Please specify clinic/hospital
and contact no. (if any)


Medical service referred to 


If unsure of medical discipline,
please specify medical conditions / symptoms



Appointment preferences



Preferred date between * (dd/mm/yyyy) 


Preferred session * 




Preferred doctor (if any) 



Contact information



Name * 


Email * 


Telephone No.* 


Please call between