Book An Appointment

Type of Patient


  • Patient Information
  • Appointment Details
  • Additional Services

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

Booking Full

Note: For new patients, customer service will be contacting you within 1 business day via email. (Please check your spam mail if you do not receive the email within 1 business day.)

Appointment Details

Doctor Image

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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?