Book An Appointment
Type of Patient
Patient Information
First Name *
Last Name *
Date of Birth *
Gender
Martial Status
Nationality
Contact Number *
Email Address *
Patient PRN Number or IC Number *
Email Address *
Appointment Details
Patient’s Name
Date of Birth
IC Number
Specialty
Doctor Name
Type of Visit
Preferred Date
Appointment Date
Selected Date
Preferred Time
Available
Selected
Not Available
Note: For new patients, your appointment will only be confirmed once Customer Service contacts you with details via email, within one business day.
(Please check your spam mail if you do not receive an email from us within one business day.)
Appointment Details
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Medical Documents (if any)
Patient Information
Island Hospital is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. By submitting this form, you may consent to us contacting you for this purpose.
In order to provide you the content requested, we need to store and process your personal data. By submitting this form, you may consent to us storing your personal data for this purpose.
If this form was submitted by an insurance agent, please check the box below.
Agent’s Name
Agency Name
Agent’s IC Number
Are there any concerns that you wish to highlight before coming for your appointment/health screening?