KLINIK PAKAR WANITA

OBGYN WOMEN'S SPECIALIST

GYNAECOLOGY, FERTILITY AND AESTHETICS CLINIC

24, Ground Floor, Jalan SS15/4D,
47500 Subang Jaya,
Selangor Darul Ehsan

t +(6)03-56316631
m

+(6)010-7778901

BY APPOINTMENTS ONLY
Call us @ HelpLine:
+(6)010-7778901

(next to Guardian Pharmacy)

 

Doctor Referral  
 
 
 
Patients Details
*Name: NRIC:
Telephone/Mobile: Email:
Age: Parity:+ LMP: / /
Gestation:weeks
 
Clinical Details
Pregnancy and childbirth
Early pregnancy Scan
Nuchal Scan
Detailed Scan
Fetal Health Scan
Gynaecology problems and Scan
Menstrual problems and Scan
Fertility problems and treatment
Sexual and Reproductive Health
Menopause
Well Women screening
Others(specify)
      
 
Special Instructions
Give patient report
Fax report
Telephone with verbal report
 
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