Xin Chinese Medical Hall (Puchong) Registration Form

心医馆之名乃医者仁心，坚守初心，致力以传统中医药理念及中医特色治疗，提高大众全方位的医疗保健平台，为您和家人之健康保驾护航。

登记前须知 Note Prior to Registration

According to the Ministry of Health (Traditional & Complementary Medicine Council, 2021 guidelines), it is compulsory for us to record the patient’s full personal details including the full name as in IC or passport. This is not for selling data, but for legal, safety and medical record purposes. Without the full name, the record will be incomplete and not valid under the law. That is why we are required to register your full name before treatment.
根据马来西亚卫生部（传统与辅助医学理事会2021年指南）规定，我们必须完整记录患者的个人资料，包括身份证或护照上的全名。此举并非用于出售数据，而是出于法律、安全及医疗记录的需要。若未登记全名，记录将不完整且在法律上无效。因此我们需要在治疗前为您登记全名。

Full Name 姓名（英文名） *

请填上和身份证或护照一致的英文名。 Please fill in your full name as per IC or passport.

IC / Passport No 身份证/护照号 *

Contact Number 联系号码 *

Address 住址 *

Please provide general area (e.g: Cheras) if you prefer not to share your full address. 如不方便提供完整地址，请提供所在的大致区域（例如：Cheras）。

Email Address 邮箱 *

How did you first hear about Xin Chinese Medical Hall? 您是通过什么方式知道心医馆? *

If other, please list down

Referral Code *If applicable

I understand and agree that the company may collect, retain, use and review my personal information, medical records and lab reports for the assessment / treatment and follow up purposes. I also agree that the company may provide / obtain to / from process reports, assessment findings, diagnostic tests / medical investigations, resulting from the services provided to you or in order to optimize the treatment to be provided to you. I agree that I have been informed of the cost of the assessment and the treatments, services, medication provided to me. I understand the company may under some circumstances bill these services to my insurance company on a third party responsible for the payment and that I am responsible for paying in full the balance of any amount not thus covered. I also understand that I will be billed for all the services recorded that may not be covered by the insurance company.

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