KPJ KL Dental Specialist Centre

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Patient Information

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Name :^*

NRIC :^*

Contact Number :^*

Please upload the front of NRIC for registration:^*

Please upload the back of NRIC for registration:^*

Email :^*

Date of Birth :^*

Gender :^*

Insurance / Company Name :
_{(It is advisable for patient to
upload the image of your Medical Card copy in the
supporting document field.)}

GL Recipient :

Requestor Information

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NRIC:

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Contact Number:

Membership Number:

Appointment details

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Select Doctor's Name^*
Select Date^*

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Select a specialty: ^*

Do you know the sub-specialty?^*

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Select Doctor's Name^*
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Please upload your Referral Letter / Guarantee Letter / Medical Card or any other supporting documents

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By submitting this Form, you hereby agree that KPJ Johor Specialist Hospital may collect, use and disclose your personal data as provided in this Form,
for the following purposes in accordance with the Personal Data Protection Act 2010 and our data protection policy.
Please visit our website at https://www.kpjhealth.com.my/dental/pdpa for further details on our data protection policy.

Patient Information

Requestor Information

Appointment details

Please upload your Referral Letter / Guarantee Letter / Medical Card or any other supporting documents

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KPJ Tawakkal – Dental Specialist Centre

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Patient Information

Requestor Information

Appointment details

Please upload your Referral Letter / Guarantee Letter / Medical Card or any other supporting documents

× Application Submitted

× Application Error

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KPJ Tawakkal – Dental Specialist Centre

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