GUARANTEE LETTER (GL) REQUEST FORM

To

PMCare Sdn Bhd

Fax. No

03-8023 9999

Careline
Email

1 300 88 6868
:

gl@pmcare.com.my

Name of Employee :___YUANNA ZAIDA BT YAHAYA_______Date : _8 May

2013_____________________
Contact No. (Mobile ):___013-3402771__________________Office:__043984842_____________________
<Please complete this form and fax/email with your referral letter OR
appointment card>
Reason for seeking treatment: (Please tick (X) where appropriate)
1st Visit (Please attach Referral Letter)
Follow up (Please attach Appointment Card)

Information on Employee & Patient:Name of

Employee

SYED NORAMIN B SYED NOR

NRIC of
Employee

781106-10-5105

Name of Patient

YUANNA ZAIDA BT YAHAYA

NRIC of Patient

781220-07-5552

Information on Referral Letter

Name of TM Panel
clinic
Name of Government
Hospital / Private
Hospital referred to
Name of Doctor you
wish to consult (if
any)
Date of visit

ADVANCED NEUROSCIENCE & ORTHOPAEDIC

CLINIC SDN BHD
DR CHEE CHEE PIN

9 MAY 2013
Please tick (X) either one:a)
b)

Fax GL to: _________________________________________Fax No. :_______________

(Name of Government Hospital/Private Hospital)

Please email me a copy of the GL: ____yuanna@tm.com.my_________________

(Email Address)

HR Helpdesk: 1 800 88 9779