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)
* Indicates required question
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
*
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. 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. 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)
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. 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. 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. 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 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 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 Mohd Raffiz Mohd Ali
Dr Thinesh Kumaran
Dr Mohd Shahir Anuar
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.
