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Guarantee Letter Request Form: To:Pmcare SDN BHD Pmcare Careline:1 300 88 6868 Fax No.:03-8023 9999
Guarantee Letter Request Form: To:Pmcare SDN BHD Pmcare Careline:1 300 88 6868 Fax No.:03-8023 9999
To
:PMCare Sdn Bhd
Fax No. :03-8023 9999
:___________________________________________________
Name of Employer
:___________________________________________________
:_______________________
Email address
:_______________________
I m portant Notice : P lease com plete this form and fax / em ail together w ith your
referral letter or appointm ent card to us.
Reason for seeking treatment; please tick () whichever approriate:For Admission
For Consultation
Follow-up Visit
(please attach
appointment card)
Outpatient
Post Hospitalization
>
Name of Employee
>
>
Name of Patient
>
>
>
>
Diagnosis
>
Date of visit/admission
>
>
Fax number
>
Email address
>