Provider Application Form
Clinic / Hospital Name *
Provider Type *
Dental
General Practitioner (GP)
Hospital
Optical
Physiotherapy
Specialist
Date Start Operation *
Company Name *
Company Registration No. *
UKAPS/CKAPS Registration No. *
Address Line 1 *
Address Line 2
City *
State *
JOHOR
KEDAH
KELANTAN
KUALA LUMPUR
LABUAN
MELAKA
NEGERI SEMBILAN
PAHANG
PERAK
PERLIS
PENANG
PUTRAJAYA
SABAH
SARAWAK
SELANGOR
SINGAPORE
TERENGGANU
Country *
Malaysia
Postcode *
Tel. No. *
Fax No. *
Email Address *
Name of Person In-Charged *
Person In-Charged Tel. No. *
Person In-Charged Email Address *
Name of Doctor In-Charged *
Doctor In-Charged MMC No. *
Doctor In-Charged Mobile No. *
Doctor In-Charged Email Address *
Services Provided *
Additional Facilities
Internet / Broadband
X-Ray Room
Open 24 hours
Operating Hours
Monday
Open
Close
Tuesday
Open
Close
Wednesday
Open
Close
Thursday
Open
Close
Friday
Open
Close
Saturday
Open
Close
Sunday
Open
Close
Consultation Charges
Day Consultation *
From
RM
Till
RM
Night Consultation *
From
RM
Till
RM
Weekend/PH *
From
RM
Till
RM
Medication Charges for Treatments
URTI / Sore Throat *
From
RM
Till
RM
Cough / Cold *
From
RM
Till
RM
Bronchitis *
From
RM
Till
RM
Gastritis *
From
RM
Till
RM
Gastroentritis / Diarrhea *
From
RM
Till
RM
Fever *
From
RM
Till
RM
Vommitting *
From
RM
Till
RM
Headache / Migraine *
From
RM
Till
RM
Dermatitis / Skin Disorder *
From
RM
Till
RM
Backache / Bodyache *
From
RM
Till
RM
Burns & Scalds *
From
RM
Till
RM
Injury & Cuts *
From
RM
Till
RM
Asthma *
From
RM
Till
RM
Sinus *
From
RM
Till
RM
Abdominal Pain *
From
RM
Till
RM
Charges for Medical Procedures
X-Ray *
From
RM
Till
RM
Ultra Sound *
From
RM
Till
RM
Dressing *
From
RM
Till
RM
Nebulizer *
From
RM
Till
RM
Minor Surgery *
From
RM
Till
RM
Charges for Lab Test
Blood Test *
From
RM
Till
RM
Blood Sugar Level Test *
From
RM
Till
RM
Urine Test *
From
RM
Till
RM
Cholestrol *
From
RM
Till
RM
Charges for Dental Treatments
Scalling *
From
RM
Till
RM
Cleaning *
From
RM
Till
RM
Extraction *
From
RM
Till
RM
Anesthetics or Antibiotic *
From
RM
Till
RM
Fillings *
From
RM
Till
RM
X-Ray *
From
RM
Till
RM
Minor Surgery *
From
RM
Till
RM
Once your application is approved by our service provider selection committee, your facility will be added to our panel and a
one-off appointment fee
will be charged for processing and activation.