Medical Report Application
Please complete the requirement application to ease the application process.
Any question or problems, freely contact us at:
03-55151871 (Avisena Specialist Hospital)
03-55151888 ext 20711 (Avisena Women's & Children's Specialist Hospital)
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Please Select Hospital
*
AVISENA SPECIALIST HOSPITAL
AVISENA WOMEN'S & CHILDREN'S SPECIALIST HOSPITAL
Relationship to Patient
*
Self
Parents/Legal Guardian
Next of Kin
Agent
Please download Consent Letter below for representative/guardian:
Consent_Letter.pdf
Name(Requestor)
*
Email Address
*
We will inform you when your application has been received
MyKad/Passport/Birth Cert/MyKid
*
Phone No.
*
Date of Request
Types of report
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Insurance
Medical Report
Immunization Record
KWSP
PERKESO/SOCSO
Discharge Summary
Copy of Medical Certificate
Investigation Report
Other
Purpose of Request
Continuity of Care
Insurance Claim
Insurance Application
Legal Proceeding
Second Opinion
Other
Admission Date
Discharge Date
Doctor's Name
Select doctor
Dr. Lukman Mohd Rashid (Consultant General Surgeon)
Dr. Mohammad Azhar Anis Ahmad (Consultant General Surgeon)
Dr. Sarinah Basro (Consultant General, Breast & Endocrine Surgeon)
Dr. Ragu A/L Ramasamy (Consultant General & Colorectal Surgeon)
Dr. Aizan Hassanuddin (Consultant Physician & Gastroenterologist)
Dr. Melven Kok Chee Shing (Consultant Physician & Gastroenterologist)
Dr. Wan Syazli Rodzaian Wan Ahmad Kamal (Consultant Plastic Surgeon)
Dr. Reynu Rajan (Consultant Upper Gastrointestinal & Bariatric Surgeon)
Dato' Dr. Mohd Hamzah Kamarulzaman (Consultant Cardiovascular & Thoracic Surgeon)
Dr. Mohamad Arif Muhammad Nor (Consultant Cardiothoracic Surgeon)
Dr. Mohd Ruslan Johan (Consultant Plastic Surgeon)
Dr. Amir Adham Ahmad (Consultant Hand & Microsurgeon)
Dr. Arman Zaharil Bin Mat Saad (Consultant Plastic Surgeon)
Dr. Ahmad Ibrahim Bin Ahmad Zaidi (Consultant Plastic Surgeon)
Dr. Muhammad Ateeq Md Jalil (Physician & Gastroenterology)
Dr. Jamil Merican Mohamed Yacob (Consultant Urologist)
Dr. Khaidhir Bin Abu Bakar (Consultant Urologist)
Dr. Rashidi bin Saidin (Consultant Physician & Nephrologist)
Dr. Mohd Raffiz Mohd Ali (Consultant Neurosurgeon)
Dr. Irene Wong (Consultant Physician & Nephrologist)
Dr. Thinesh Kumaran A/L Jaya Raman (Consultant Neurosurgeon)
Dr. Stefanie Hung Kar Yan (Consultant Physician & Neurologist)
Dr. Mohd Ramadhan Bin Mohd Din (Consultant Physician & Nephrologist)
Dr. Anna Misya'il Abdul Rashid (Physician & Neurologist)
Dr. Anna Misya'il Abdul Rashid (Physician & Neurologist)
Dr. Mohd Mahamud Mohd Musman (Consultant Orthopaedic & Trauma Surgeon)
Dr. Khaizatul Ezam bin Abu Bakar (Consultant Orthopeadic & Trauma Surgeon (Arthroscopy & Sports Injury))
Dr. Ahmad Zubair Bin Anis Ahmad (Consultant Orthopaedic & Trauma Surgeon)
Dr. Mohd Khairuddin Bin Kandar (Consultant Orthopaedic & Spine Surgeon)
Dr. Ariff Sukimin Mohammad Shukri (Consultant Orthopaedic and trauma surgeon)
Dr. Nor Hamdan Mohamad Yahaya (Consultant Orthopaedic Surgeon)
Dr. Mohamed Faizal Hj Sikkandar (Consultant Orthopaedic & Trauma Surgeon)
Dr. Kamarulzaman Haji M.S Kadir (Consultant Orthopaedic Surgeon)
Dr. Muhammad Azrin Mohd Asihin (Consultant Orthopaedic Surgeon)
Dr. Fazrina Ayu Binti Abdul Sani (Consultant Orthopaedic & Paediatric Orthopaedic Surgeon)
Dr. Thuraikumar A/L Kanniah (Consultant Orthopaedic Surgeon)
Dr Amir Adham Ahmad (Consultant Hand & Microsurgeon)
Dr. Mohamed Faizal Bin Hj Sikkandar
Dr Mohd Yusoff Bin Yahaya
Dr. Faizal Nazli Bin Osman
Dr. Nurhanani Binti Abu Bakar
Dr. Ahmad Zubair Bin Anis Ahmad
Dr. Mohd Mahamud Bin Mohd Musman
Dr. Khaizatul Ezam Bin Abu Bakar
Dr. Mohd Khairuddin Bin Kandar
Dr. Ariff Sukimin Bin Muhammad Shukri
Dr. Faizal Nazli Bin Osman
Dr. Nurhanani Binti Abu Bakar
Dato' Dr. Abdul Rahman Mohd Ali (Consultant Physician & Cardiologist)
Datin Dr. Noraziah Abdul Kadir Jailani (Consultant Physician & Dermatologist)
Dr. Zal bt Ab Rahim @ Ahmad (Consultant Physician & Respiratory Medicine)
Dr. Mahmood Sabruddin Bin Zulkifli (Consultant Physician & Cardiologist)
Dr. Kartini Farah Abdul Rahim (Consultant Dermatologist)
Dr. Mohd Firdaus Bin Hadi (Consultant Physician & Cardiologist)
Dr. Najwa Hanim Binti Md Rosli (Consultant Neuropsychiatrist / Psychiatrist)
Prof Dato' Dr Rosman Ab Rahman (Consultant Physician)
Dr. Zulkeflee Muhammad (Consultant Cardiology)
Dr. Ainil Hawa Ibrahim (Rehabilitation Physician)
Dr. Azura Rozila Ahmad (Consultant Medical Oncologist)
Dr. Mohd Faiz Bin Md Tahir (Consultant Psychiatrist)
Dr. Hazli Bin Zakaria (Consultant Psychiatrist)
Assoc. Prof. Dr. Mohamed Faisal Bin Abdul Hamid (Consultant Physician & Respiratory Medicine)
Dr. Sapini Binti Yacob (Consultant Psychiatrist)
Dr Mohammad Arif Shahar (Consultant Endocrinologist)
Dato' Dr. Abd Razak Rahman Hamzah (Consultant ENT, Head & Neck Surgeon)
Dr. Loganathan A/L Athanari (Consultant ENT, Head & Neck Surgeon)
Dr. Roslenda Abdul Rahman (Consultant ENT, Head & Neck Surgeon)
Dr. Iqbal Farim Bin Rizal Wong (Consultant ENT, Head & Neck Surgeon)
Dr. Ahmad Kusyairi Bin Khalid (Consultant ENT, Head & Neck Surgeon)
Prof. Dr. Mohd Razif Mohamad Yunus (Consultant ENT)
Prof. Dato' Dr. Abdullah Sani Bin Mohamed (Consultant ENT)
Dr Farah Hani bt. Hassan
Dr. Iqbal Farim Bin Rizal Wong
Dr. Roslenda Binti Abdul Rahman
Dato' Dr. Abdul Razak Rahman Hamzah
Dr. Loganathan A/L Athanari
Dr. Ahmad Kusyairi Bin Khalid
Dr. Siti Haida Md. Isa (Consultant Ophthalmologist)
Dr. Norwazilah Binti Mohd Ansul (Consultant Ophthalmologist)
Dr. Anis Farhad Murshid (Consultant Ophthalmologist)
Dr. Nor Akmal Binti Bahari (Consultant Paediatric Ophthalmologist)
Dr. Roslin Azni Binti Abdul Aziz
Dr. Nurul Faaiqah Binti Jainuddin
Dr. Nor Akmal Binti Bahari
Dr. Siti Haida Bin Md. Isa
Dr. Norwazilah Binti Mohd Ansul
Dr. Nurul Faaiqah Binti Jainuddin
Dr. Firdaus Bin Hanapiah (Consultant Oral & Maxillofacial Surgeon)
Dr. Hazmyr Bin Abdul Wahab (Consultant Oral & Maxillofacial Surgeon)
Dr. Kathiravan A/L Perumal (Consultant Oral & Maxillofacial Surgeon)
Dr Noor Ilyani binti Othman
Dr Nabihah binti Dziaruddin
Dr Siti Mariam binti Ab Ghani
Dr Lily Azura binti Shoaib
Dr Norazlina binti Ismail
Dr. Aufa Dahlia Binti Bahar
Dr. Firdaus Bin Hanapiah
Dr. Tengku Arizal Tengku Abdullah
Dr. Abdul Hafiz Abd Wahab
Dr. Gulam Mohamed Munshi Deen
Dr. Norhayati Nadirah Nadarrudin
Dr. Amerjeet Singh
Dr. Mohammad Nazir Jemoin
Dr. Prasath A/L Nadarajan
Dr. Adam Marzuki bin Ismail
Dr. Vimaldass A/L P.Balashanmugam
Dr. Rupa Shakila A/P Arumugam
Dr. Sivaa Prakash A/L Subramaniam
Dr. Khairunnisa Liana binti Ismail Hashim
Dr. Farah Ainn binti Mohtar
Dr Samnudi bin Yusof
Dr. Sharvananthi Kobala Krishnan
Dr. Sharvananthi Kobala Krishnan
Dr. Nik Rushda Syazana Nik Rohaizad
Dr. Nik Rushda Syazana Nik Rohaizad
Dr Fadzillah Binti Ghazalli
Dr Fazila Binti Mohamed Kutty
Dr Iftikhar Ahmad Bin Mohamed Akup
Dr Roliza Binti Ibrahim
Dr Shariza Binti Lukman
Dr Sherina Sheereen Binti Rizlan Ross
Dr Syariz Izry Sehat
Dr Tan Eng Kian
Dr Varughese Koshy
Dr Vidya Theivanayagi A/P Natthondan
Prof Dato' Dr Abdullah Sani Bin Mohamed
Dr Mohammad Nawar Ariffin
Dr Fazrina Ayu Abdul Sani
Dr Ashikin Mohd Noridn
Dr. Nirmala A/P Ponnuthurai
Dr Nazatul Sabariah Binti Ahmad
Prof. Dr Bilkis Banu Shri Abd Aziz
Dr Charlotte Sundaraj
Dr. Ding Sook Ling
Dr. Nor Azira Binti Ismail
Dr. Sharifah Wade'ah Wafa Binti Syed Saadun Tarek Wafa
Dr. Tengku Maryam Fatimah Binti Tengku Ab Malek
Dr. Hafatin Fairos Binti Tamaddun
Dr. Mohd Razin Bin Hassan
Dr Fairuz A'shikin Binti A Kadir
Dr Jumeah Binti Shamsuddin
Dr Mazita Binti Mashor
Dr Norazhana Binti Mohamad
Dr Norleen Binti Mohd Salleh
Dr Raja Arif Shah Bin Raja Ismail
Dato' Dr Zamri Bin Abdul Rahim
Prof Dr Mohd Hashim Omar
Prof Dr Ani Amelia Zainuddin
Prof Dr Mohd Nazri bin Yazid
Dr. Fauziah Binti Jummaat
Dr Ahmad Murad Zainuddin
Dr Abdul Kadir Abdul Karim
Dr Muhammad Azrai Abu
Dr. Thaneemalai Jeganathan
Dr. Akmal Hisyam Bin Arshad
Dr. Akmal Zulayla Binti Mohd Zahid
Dr. Siti Maisarah Binti Ahmad
Dr. Maryam Sakinah Binti Mohamad Rom
Dr. Nur Azwin Binti Hamran
Dr. Akmal Hisyam Bin Arshad
Dr. Akmal Zulayla Binti Mohd Zahid
Dr. Thaneemalai Jeganathan
Dr. Siti Maisarah Binti Ahmad
Dr. Jerilee Mariam Khong Binti Azhary
Dr. Maryam Sakinah Binti Mohamad Rom
Dr. Nur Azwin Binti Hamran
Dr Mohd Raffiz Mohd Ali
Dr Thinesh Kumaran
Dr. Badrisyah Bin Idris
Dr. Badrisyah Bin Idris
Dr Mohd Shahir Anuar
Dr. Mohd Shahir Bin Anuar
Col (R) Dato' Dr. Jaseemuddeen Bin Abu Bakar
Dr. Muhd Helmi Bin Azmi
Dr. Wan Afaf Binti Zainal Abidin
Dr. Esa Bin Kamaruzaman
Dr. Jenny Phang Chin Hee
Dr. Navina Thiagarajah
Dr. Raveenthiran A/L Rasiah
Dr. Kevin Yong Vai Ket
Dr. Arnil George Sirimanne
Dr. Supriya A/P V Menon Ravindra
Dr. Syaman A/L Harry
Dr. Ahmad Afkhar Fakhrizzaki
Dr. Zaidah Binti Mohd Ismail
Dr. Mohd Hanif Bin Amran
Dr. Nik Azuan Bin Nik Ismail
Dr. Zaidah Binti Mohd Ismail
Dr. Ahmad Afkhar Fakhrizzaki
Dr. Syaman A/L Harry
Dr. Mohd Hanif Bin Amran
Dr. Supriya A/P Menon Ravindra
Dr. Nik Azuan Bin Nik Ismail
Dr. Manohar A/L Padmanathan
Dr. Adrian Mark A/L Masnammany
Dr. Fadzliana Hanum Binti Hj Jalal
Dr. Wan Syazween Lyana Binti Wan Ahmad Kammal
Dr. Mohd Razin Bin Hassan
Dr. Hamidah Binti Mohd Zainal
Dr. Wan Syazli Rodzaian Bin Wan Ahmad Kamal
Dr. Hamidah Binti Mohd Zainal
Dr. Khaidir Bin Abu Bakar
Dr. Jamil Merican Bin Mohamed Yacob
Dr. Khaidir Bin Abu Bakar
Dr. Raveenthiran A/L Rasiah
Dr. Navina Thiagarajah
Dr. Kevin Yong Vai Ket
Dato' Dr. Jaseemuddeen Bin Abu Bakar
Dr. Jenny Phang Chin Hee
Dr. Wan Afaf Binti Zainal Abidin
Dr. Muhd Helmi Bin Azmi
Dr. Esa Bin Kamaruzaman
Dr. Wan Syazween Lyana Bt Wan Ahmad Kammal
Dr. Zasmani Binti Shafiee
Dr. Najwa Hanim Binti Md Rosli
Dr. Muhammad Ateeq Md Jalil (Physician & Gastroenterology)
Collection Method
*
Self- Collection
Postal services
Delivery Address
*
MyKad/Birth Cert/MyKid/Passport Patient
*
Choose file
MyKad Parents/Legal Guardian /MyKad Next Of Kin/MyKad Agent
if patient is below 18 years old, NRIC parents is required
Choose file
Consent Letter
*
Representative, agent, lawyer etc is required
Choose file
Documentations
*
Please upload PDF file only. You can upload multiple files
Choose file
Kindly read the Personal Data Protection Notice below:
Personal Data Protection Notice
Consent to release information
I have read and understood the Personal Data Protection Notice and I hereby give my consent to AVISENA to process my personal data for the purposes stated in the Personal Data Protection Notice. I also warrant that I have sought the consent of any third party whose personal data I have disclosed to AVISENA I also do hereby consent and permit AVISENA to issue the medical report and relinquish AVISENA and its healthcare providers from any legal action related to it.
You must agree before submitting.
