Form

Registration for/Upgrade to Premium Membership or

Proxy Nomination

Use this form to register for/upgrade to Premium Membership to access your own medical information or nominate a proxy. Complete it and send to NetCare Internet Services, 6 Commonwealth Lane #05-01/02 GMTI Building S(149547).

As this service involves certain confidential information, applicants who are:

§ Above 21 years are required to attach a copy of your IC (both sides) or passport for verification purposes.

§ Under 21 years are required to include parent’s written consent, a copy of parent’s IC (both sides) and birth certificate for verification purposes.

For proxy nomination, submit a copy of the nominated proxy’s IC (both sides). If the proxy is your General Practitioner (GP), proxy’s IC not required.

For enquiries, please call 6471 8989 or write to enquiries@netcare.nhg.com.sg

A. About the Patient
Name (as in NRIC/Passport):
NRIC/Passport No:		Date of Birth:			Gender: Male/Female
Email Address:
Mailing Address:
Contact Numbers:	Home			Office
	Mobile			Pager
Preferred Institution:	q Alexandra Hospital q National University Hospital q Tan Tock Seng Hospital			q Institute of Mental Health /Woodbridge Hospital q National Skin Centre q NHG Polyclinics
B. Proxy Nomination
You may allow another person – known as Proxy – to access your information. Please provide your proxy’s details.
Proxy’s Name (as in NRIC/Passport):
NRIC/Passport No:			Date of Birth:		Gender: Male/Female
Email Address:			Contact Number:
Mailing Address:
The nominated Proxy is the ________________ of the patient (specify relationship)
If the nominated proxy is your GP, please complete the following:
GP Name:
GP Clinic:
GP Clinic Address:
GP Clinic Tel:
C. Agreement
I have read the Terms and Conditions as listed on the NetCare website at www.netcare.com.sg and agree to abide and be bound by the Terms and Conditions and any amendments, alterations and additions as may be made from time to time. __________________________ _______________ Signature Date