Registration

Registration of new patients can be either done prior to your visit by pre-registering or during your first visit to our clinics. We ask that new patients arrive 10 minutes before their appointment so that any required forms can be completed and baseline measurements of height, weight, and blood pressure can be taken before you are seen by the doctor.

If you would like to pre-register with us, please complete the required registration form below. Before you complete your registration form, please read our Important Clinic Information and Patient Privacy Policy to learn more about our services.

Please fill in the details below:

Date*
Date Format: DD slash MM slash YYYY
Do you have an appointment scheduled*
- Yes
- No
Registration Form*
Clinic*
Title*
Family Name (Surname)*
Given Names*
Date of Birth*
Date Format: DD slash MM slash YYYY
Passport/NRIC/FIN/Birth Certificate No*
Nationality*
Marital Status*
Sex
Email Address*
Contact Details
Block/House Number and Street Name*
Unit Number and Building Name*
Country*
Postcode*
Temporary Address
- Yes
Contact Number*
Parents Details - Complete if completing on behalf of a minor <16
Mother's Name*
Mother's Telephone Number*
Mother's Email*
Father's Name*
Father's Telephone Number*
Father's Email*
Next of Kin/Emergency Contact Details
Name*
Telephone*
Relationship*
Medical History
Do you have any know allergies to drugs?*
Does your child have any know allergies to drugs?*
More Information*
Are you taking any medication?*
Is your child currently taking any medication?*
More Information*
Do you drink alcohol?*
Do you smoke?*
Any active medical condition or medical history?*
More Information*
Medical History
Surgical History
Family Medical History
Birth Weight
Main Caregiver
School
Medical Insurance
Would you like to hear from us?
Please tick if you would like to receive notifications from us about:
- Health Alerts and Clinic Information - Doctor Announcements, IMC Health Update and Important Clinic Information
Terms & Conditions
Signature
Terms & Conditions*
- Please confirm that you have read and understood the contents of the Important Clinic Information sheet
- Please confirm that you have read and understood the contents of the Patient Privacy Policy sheet

Registration

Registration of new patients can be either done prior to your visit by pre-registering or during your first visit to our clinics.

Registration

Contact Details

Parents Details - Complete if completing on behalf of a minor <16

Next of Kin/Emergency Contact Details

Medical History

Would you like to hear from us?

Terms & Conditions

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