"*" indicates required fields Date* DD slash MM slash YYYY Attending the appointment* Minor visiting on their own Minor visiting with guardian Clinic*-- Please Select --CamdenJelitaKatongChildren'sDoctor*-- Please Select --Any DoctorDr Ho Tzin YihDr Phua Sin RuDr Valerie DruonDr Tan Lih YiDr Heather KingDr Vinu SahlénDr Nandini ShahDr Sonali DassDoctor*-- Please select --Any DoctorDr Lim Hui LingDr Woo Boon PengDr Navjot UppalDr Christopher EldridgeDr Nicole ReidyDr Melissandre NoelDr Laura BiffinDoctor*-- Please select --Any DoctorDr Bernadetta WibisonoDr Arti JaiswalDr Gina DahelDr Shivani PaliwalDoctor*-- Please select --Any DoctorDr Sundus Hussain-MorganDr Maria TangDr Charu NarayananDr Rebecca DalyPatient Full Name (as per NRIC/Fin number/Passport)* Date of Birth* DD slash MM slash YYYY Sex*-- Please select --MaleFemaleVisit Date* DD dash MM dash YYYY This consent is only valid for the visit date selected if multiple visits are required you must submit multiple consents. Full Name of Accompanying Adult* Relationship to Patient of Accompanying Adult* Full name of parent / legal guardian* Parents Contact Number*Must be available at this number during the consultationParents Email* Reason for Visit*This must detail the exact nature of the visit for example administer BCG vaccine to your child. You must be as specific as possible.- All minor under 16 years must have parents consent from all consultation. - All children above 12 years should ideally sign this form. - Doctors need to use their discretion as to the need for this form to be properly completed by all parties. - Doctor will use their discretion in rendering medical treatment in case of emergency. - If consent is obtained by phone, the doctor may decide to advise the parent that this form will be sent as follow-up to obtain their signature for our records. Signature of Parent*Consent* I hereby authorise and give consent to the attending doctor of International Medical Clinic to render medical care and/or treatment as may be found necessary during the course of the consulation. NameThis field is for validation purposes and should be left unchanged.