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Child's Full Name
First Last
Email*
Phone*
Date of Birth*
DD slash MM slash YYYY
Sex*
Parent/Guardian Full Name
First Last
For children under the age of 16 years, a parent/guardian must be present with the child during consultation.
Have you travelled in the past 3 weeks? If yes, where?
Clinic*
Preferred Doctor*
Preferred Doctor*
Preferred Doctor*
Preferred Doctor*
Preferred Date*
DD slash MM slash YYYY
Preferred Time*
Is this your first visit?*
Would you like to discuss any of the below? (additional cost may occur)*
- Sexuality
- Substance Abuse
- Mental Health and Behaviour
- None
Any Specific Concern to be discussed?
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Kindly fill in your data and complete the checklist below. If you have any other information and enquiry, please advise the nurse prior

"*" indicates required fields

Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Phone*

Clinic*

Have you had influenza vaccination before?*

Are you allergic to Eggs?*

Have you had any reactions post influenza vaccination previously*

Have you had any other vaccinations done recently?*

Vaccines information

Date of Vaccine

DD slash MM slash YYYY

Have you been ill for the last 7 days? If Yes Please specify*

If you develop an illness after you have already been given an appointment, please call the clinic for advice

Please specify*

Signature

"*" indicates required fields

Name as per NRIC/FIN/Passport*

Prefix First Last

Date of Birth*

DD dash MM dash YYYY

Address in Singapore*

Street Address Floor and Unit # ZIP / Postal Code

Type of Swab Test*

Please note:*

I have read, understood and agreed to proceed with the test.

If you have recovered from Covid-19 in the last 6 months, a PCR result may still be positive.
if Infection is not recorded with IMC Clinics and you require a recovery certificate for travel, you need a Doctor's appointment to issue a recovery Memo.

What is the reason for your Test?*

PLEASE SELECT THE TYPE OF APPOINTMENT YOU REQUIRE**

Dropping off Sample/s

Do you have any medical conditions where you should not have a nasal swab?*

This includes the risk of nose bleed, clotting problems, deviated nasal septum, previous nasal or base of skull fracture/injury.

Select if Yes*

Higher rish of nasal bleeding

Frequent epistaxis

Severe coagulopathy

Deviated nasal septum

Previous nasal or base of skull fracture

Injury, history of NPC

Preferred Date of Appointment*

DD slash MM slash YYYY

Please check with your destination country PCR/ART testing requirements.

Time*

Hours

Minutes

AM/PM

Additional Travelers requiring Swab on the same itenary*

Traveler 1 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 1 Copy of Passport*

Max. file size: 50 MB.

Traveler 2 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 2 Copy of Passport*

Max. file size: 50 MB.

Traveler 3 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 3 Copy of Passport*

Max. file size: 50 MB.

Traveler 4 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 4 Copy of Passport*

Max. file size: 50 MB.

Traveler 5 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 5 Copy of Passport*

Max. file size: 50 MB.

Traveler 6 NRIC/FIN card*

Max. file size: 50 MB.

Traveler 6 Copy of Passport*

Max. file size: 50 MB.

Applicant Email Address*

Please note that this email address will be used for all additional travellers.

Applicant Contact Number*

Clinic*

Agreement*

By signing this form, I agree to the following conditions set out below:

I confirm that the requested appointment meets my destination country's requirements

I confirm that I have provided all required documentation

I confirm that I have declared any contra-indications to undergo nasal swabbing

I acknowledge that IMC accepts no responsibility or liability for any missed flights due to inconclusive results or any other unpredictable factors that may occur (for travellers)

I understand if my Covid Test returns positive, any travel will be prohibited and MOH will be notified

Signature*

"*" indicates required fields

Please Note: Adults must authorize the release of their own medical file i.e. a person cannot authorize the release of their spouse's medical file. A consenting parent/guardian can sign on behalf of children under the age of 18.

Patient(s) Information:*

Name of Patient

Date of Birth

Are you Relocating?*

Yes

Any additional Information?*

Date you require patient records (Please note that we have a processing time of 7-14 days). If you have future appointments booked, please be sure to select a date after your last visit to our clinic*

Phone Number*

Email Address*

Signature*

Acknowledgement*

Please note - If you are set up for Insurance Direct Billing and relocating, we can no longer direct bill with your insurer after we have released your patient record. All future visits will be self-paid, whereby you can proceed to claim directly with your insurer.

Consent*

I/We hereby formally request and grant authorization to the International Medical Clinic for the release of information contained within the medical files pertaining to the patient(s) listed below. Please be aware that for adults, authorization is specifically required from the individual to release their own medical records; for instance, one cannot grant permission to access a spouse's medical file. In the case of minors under the age of 18, a consenting parent or guardian may sign on their behalf. To ensure the utmost security and confidentiality, your medical records will be encrypted and subsequently sent to your designated email address. Furthermore, an OTP (One-Time Password) will be sent to you via email, serving as an additional layer of security for accessing your records.

"*" indicates required fields

Family Name (Surname)*

Given Names*

Date of Birth*

DD dash MM dash YYYY

Contact Number*

Email Address*

Clinic*

Doctor

Medication Details*

Medication

Strength

Quantity

Comments*

Name

This field is for validation purposes and should be left unchanged.

"*" indicates required fields

Please complete this form and one of our receptionists will call you back to confirm the time and date for your bespoke Health Screening.

Given Names*

Family Name (Surname)*

Date of Birth*

DD dash MM dash YYYY

Gender*

Email*

Contact Number*

Preferred Date*

DD slash MM slash YYYY

Preferred Time*

Hours

Minutes

AM/PM

Clinic*

Is this your first visit?*

Preferred Doctor*

To save time in the clinic don't forget to pre-register with us online.

View Form

Clinic

PART A: PERSONAL PARTICULARS

Name as per NRIC/FIN/Passport No.(Required)

NRIC No./Foreign Identification No. (FIN)/Passport No.(Required)

Passport No. (only if you do not have a NRIC/ FIN number)

*Please note that a NRIC or FIN number is required in order to enter your vaccination details into the National Immunisation registry and your Trace Together app.

Gender(Required)

Male

Female

Prefer not to answer

Date of Birth(Required)

DD slash MM slash YYYY

Address(Required)

Block# and Building Name Unit# ZIP / Postal Code

Phone Number(Required)

Email Address(Required)

PART B: MEDICAL INFORMATION

PART B1: FEVER & VACCINATION

Have you had a fever or any vaccination recently?

Fever (Temperature ≥38.5°) in the past 24 hours?

Yes

Any vaccination in the past 14 days?

Yes

Vaccination Details(Required)

Have you had any COVID-19 vaccinations before?

Yes

Name of Vaccination #1

Date

DD slash MM slash YYYY

Name of Vaccination #2

Date

DD slash MM slash YYYY

Have you had COVID-19 infection before?

Yes

Date of first positive PCR test

DD slash MM slash YYYY

Have you received a Health Risk Warning in the last 14 days?

Yes

Do you currently have fever (≥37.5°C), flu like symptoms (e.g. runny nose, cough, shortness of breath), sore throat, body ache, loss of smell, etc?

Yes

PART B2: IMMUNOCOMPROMISE (additional counselling will be required before vaccination)

Do you have any medical conditions causing severe immunocompromise?

Recent transplant in the past 3 months

Yes

On cancer treatment (immunotherapy/chemotherapy/radiotherapy)

Yes

Aggressive Immunotherapy for non-cancer conditions (eg. rituximab etc)

Yes

HIV

Yes

PART B3: ALLERGIES

Have you ever had any severe allergic reactions to vaccines, medications or insect stings?

Anaphylaxis: severe reaction with two or more of the following: (a)hives or face/eyelid/lip/throat swelling, (b) difficulty breathing, (c) dizziness

Yes

Ever been prescribed Epi-Pen? (Self-injected epinephrine for severe allergy)

Yes

Severe skin rash AND mouth/genital ulcers/red eyes/liver injury due to medications? (TEN/SJS/DRESS/DiHS)

Yes

Have you had rash OR hives OR face/eyelid/lip swelling to vaccines?

Yes

PART B4: OTHER PRECAUTIONS (CAN STILL VACCINATE)

Are you currently taking these medications or have these medical conditions?

Blood-thinning medications (eg. warfarin, apixaban, rivaroxaban etc)

Yes

Bleeding disorder or low platelets

Yes

PART B5: PREGNANCY & RELATED QUESTIONS (FOR FEMALES ONLY)

Are you pregnant or suspect that you are pregnant (late menstrual period)?

Yes

Are you currently breastfeeding? (CAN STILL VACCINATE)

Yes

PART C: PATIENT DECLARATION AND CONSENT

Declaration

I declare that the information I have given is true and complete to the best of my knowledge

Declaration

I have been informed of the risks, benefits and side effects of COVID-19 vaccination, and I wish to receive COVID-19 vaccination

Consent

I AGREE to receive COVID-19 vaccination

Signature

Still have questions?

If you have any questions please complete the form below and one of our helpful team will be in touch.

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First Last

Contact Number(Required)

Email(Required)

Message(Required)

Insurance companies we work with

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Adolescent Health Screening

Declaration / Checklist for Flu Vaccination

Patient Agreement to Covid Swab

Release of Patient Medical Information

Repeat Prescriptions

Request a Health Screening

Health Screening QNR

Sinopharm Covid-19 Vaccination Request

PART A: PERSONAL PARTICULARS

PART B: MEDICAL INFORMATION

PART B1: FEVER & VACCINATION

PART B2: IMMUNOCOMPROMISE (additional counselling will be required before vaccination)

Do you have any medical conditions causing severe immunocompromise?

PART B3: ALLERGIES

Have you ever had any severe allergic reactions to vaccines, medications or insect stings?

PART B4: OTHER PRECAUTIONS (CAN STILL VACCINATE)

Are you currently taking these medications or have these medical conditions?

PART B5: PREGNANCY & RELATED QUESTIONS (FOR FEMALES ONLY)

PART C: PATIENT DECLARATION AND CONSENT

Still have questions?

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