GP Referral

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Patient Referral Form

Al-Islam Specialist Hospital · Referring GP / Clinic

Referring Clinic

Clinic Name *

Clinic Email *

Clinic Address *

Clinic Phone Number *

Referring Doctor

Doctor’s Full Name *

Medical Registration Number *

Patient & Appointment

Patient’s Name *

Patient’s Phone Number *

Date Appointment with Us *Tap the field to open the calendar and pick your preferred date. Subject to doctor’s availability.

Diagnosis *0 / 3000

Specialty & Source

Specialty *

How do you know about Al-Islam Specialist Hospital? *

Terms & Consent

Terms & Conditions

All appointment forms, emails, and WhatsApp messages will be attended to within 24 hours (excluding Sundays and public holidays). Please submit requests at least 2 days in advance and wait for confirmation from the clinic before attending. Requested dates are subject to the doctor’s availability. For available dates, contact us at +603-2693 1007 or WhatsApp +6019-310 7889.

I have read and agree to the Terms & Conditions.

Personal Data Protection Notice (PDPA)

I hereby consent that my personal data, including my medical and health information, may be collected, used, processed and disclosed by the referring GP Clinic and the receiving Hospital for purposes related to my referral, medical assessment, diagnosis, treatment, care coordination and related administrative matters.

I understand that my personal data will be handled in accordance with applicable laws and regulations, including the Personal Data Protection Act 2010 (PDPA), where applicable, and relevant healthcare confidentiality requirements. My information will only be disclosed to authorised parties where necessary for the purposes stated above or as otherwise permitted or required by law.

I consent to the Personal Data Protection Notice above.

Emergency Number: +603-2693 1007

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