CARING FROM THE HEART OF THE CITY

Appointment

Fields marked with an * are required

Patients Particulars

Patient Name *

Salutation

Nationality *

Contact No *

Email *

Gender

Male
Female

Patients Current Medical Conditions Symptoms or Diagnosis

Preferred Appointment Period

Preferred Practitioner *

Preferred Clinics *

Date *

Timeslot *

Translators Required

Remarks

By providing my personal data and submitting this enquiry, I consent to the owner of the relevant Unit and/or his/her/its agent(s) and/or other nominated or designated persons or entities (the “Relevant Persons”) to collect, use, disclose and/or process all my personal data (which I input into this enquiry form and/or which is otherwise made available to any of the Relevant Persons, whether by me or otherwise), in order to process and/or respond to my request, query, feedback or comments (collectively “Enquiries” and each, an “Enquiry”) and/or otherwise to carry out any transaction pursuant or further to my Enquiry (including but not limited to any purchase or leasing transaction).

I confirm and agree that my consents above do not supersede or replace any other consent which I previously provided to any of the Relevant Persons in respect of my personal data, and is additional to any rights which any of the Relevant Persons may have at law to collect, use, disclose and/or process my personal data.