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Reg. No 199002477Z CLINICAL ABSTRACT APPLICATION FORM MD 105 Instructions This form must be fully completed for the application of a medical report. Address FOR OFFICIAL USE Application is approved / not approved Name and Designation of Approving Officer Clinical Abstract Application Form 09/2008. It should be signed by the patient or the patient s parent if patient is below 21 years of age or the patient s next of kin if patient is deceased and be duly witnessed* This form is to be submitted with the appropriate report fee. The release of the medical report is subject to official approval* Medical Superintendent Hospital / Clinic hereby authorize you to furnish Prudential Assurance Company Singapore Pte Limited of 30 Cecil Street 30-01 Prudential Tower Singapore 049712 with a medical report on Name of patient NRIC / Hospital Registration No* who was treated at the hospital as a patient in The department of from to The medical report is required for the purpose specified below Besides the medical report fee I undertake to pay any additional charges such as X-ray and laboratory investigation charges which may be incurred in the preparation of the medical report. Name in block letters Relation to patient Signature of Patient / Parent / Next-of-Kin Duly Witnessed By Signature NRIC NO. It should be signed by the patient or the patient s parent if patient is below 21 years of age or the patient s next of kin if patient is deceased and be duly witnessed* This form is to be submitted with the appropriate report fee. The release of the medical report is subject to official approval* Medical Superintendent Hospital / Clinic hereby authorize you to furnish Prudential Assurance Company Singapore Pte Limited of 30 Cecil Street 30-01 Prudential Tower Singapore 049712 with a medical report on Name of patient NRIC / Hospital Registration No* who was treated at the hospital as a patient in The department of from to The medical report is required for the purpose specified below Besides the medical report fee I undertake to pay any additional charges such as X-ray and laboratory investigation charges which may be incurred in the preparation of the medical report. The release of the medical report is subject to official approval* Medical Superintendent Hospital / Clinic hereby authorize you to furnish Prudential Assurance Company Singapore Pte Limited of 30 Cecil Street 30-01 Prudential Tower Singapore 049712 with a medical report on Name of patient NRIC / Hospital Registration No* who was treated at the hospital as a patient in The department of from to The medical report is required for the purpose specified below Besides the medical report fee I undertake to pay any additional charges such as X-ray and laboratory investigation charges which may be incurred in the preparation of the medical report. Name in block letters Relation to patient Signature of Patient / Parent / Next-of-Kin Duly Witnessed By Signature NRIC NO. It should be signed by the patient or the patient s parent if patient is below 21 years of age or the patient s next of kin if patient is deceased and be duly witnessed* This form is to be submitted with the appropriate report fee. The release of the medical report is subject to official approval* Medical Superintendent Hospital / Clinic hereby authorize you to furnish Prudential Assurance Company Singapore Pte Limited of 30 Cecil Street 30-01 Prudential Tower Singapore 049712 with a medical report on Name of patient NRIC / Hospital Registration No* who was treated at the hospital as a patient in The department of from to The medical report is required for the purpose specified below Besides the medical report fee I undertake to pay any additional charges such as X-ray and laboratory investigation charges which may be incurred in the preparation of the medical report. Name in block letters Relation to patient Signature of Patient / Parent / Next-of-Kin Duly Witnessed By Signature NRIC NO.