This form is not intended for setting appointment. This is WQPark patient membership form. Patient will receive newsletter by registering here. Doctors will get basic info of patients by refering to this registration also. For setting appointment, please go to appointment page. Thank you.
Patient Details    
Patient Name * :
IC No :
Age :
Gender * :
Date Of Birth :
Address :
Postcode :
Contact No * :
Email * :
     
Medical Details    
Specialties :
Consultants :
Allergies :
Remark :
 
 
 
 
 
     
  Copyright @ 2012 WQ Park Health & Rehabilitation Centre [ Admin Login ] Powered By DATA nGEN TECH (M) Sdn Bhd