Get Clinical Abstract Format

MEDREP Clinical Abstract Application Form CA1 A. Particulars of Life to be Assured / Assured Name NRIC/ Passport / B.C. No. Contract No. Instruction This form must be fully competed for the application of a medical report. 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* To Doctor / Medical Officer In-Charge Clinic / Hospital Address I hereby authorise you to furnish AVIVA LTD of 4 Shenton Way 01-01 SGX Centre 2 Singapore 068807 with a medical report on Name of Patient NRIC / Birth Cert / Passport No* who was treated at the clinic/hospital as a patient in the Department of from Admission Date to Discharge Date. The Medical report is required for the purpose s specified below Signature of Patient/Parent/Next-of-kin Signature of W itness / Date Relationship to Patient FOR OFFICIAL USE Application is Approved/Not Approved Signature Date Name and Designation of Approving Officer Delete as appropriate Page 1 of 1 Aviva Ltd 4 Shenton W ay 01-01 SGX Centre 2 Singapore 068807 Tel 65 6827 7988 Fax 65 6827 7900 www. aviva-singapore. com*sg Company Reg* No* 196900499K GST Reg* No* MR-8500166-8 Navigator Investment Services Ltd Company Reg* No* 200103470W GST Reg* No* 20-0103470-W. 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* To Doctor / Medical Officer In-Charge Clinic / Hospital Address I hereby authorise you to furnish AVIVA LTD of 4 Shenton Way 01-01 SGX Centre 2 Singapore 068807 with a medical report on Name of Patient NRIC / Birth Cert / Passport No* who was treated at the clinic/hospital as a patient in the Department of from Admission Date to Discharge Date. The release of the medical report is subject to official approval* To Doctor / Medical Officer In-Charge Clinic / Hospital Address I hereby authorise you to furnish AVIVA LTD of 4 Shenton Way 01-01 SGX Centre 2 Singapore 068807 with a medical report on Name of Patient NRIC / Birth Cert / Passport No* who was treated at the clinic/hospital as a patient in the Department of from Admission Date to Discharge Date. The Medical report is required for the purpose s specified below Signature of Patient/Parent/Next-of-kin Signature of W itness / Date Relationship to Patient FOR OFFICIAL USE Application is Approved/Not Approved Signature Date Name and Designation of Approving Officer Delete as appropriate Page 1 of 1 Aviva Ltd 4 Shenton W ay 01-01 SGX Centre 2 Singapore 068807 Tel 65 6827 7988 Fax 65 6827 7900 www. The Medical report is required for the purpose s specified below Signature of Patient/Parent/Next-of-kin Signature of W itness / Date Relationship to Patient FOR OFFICIAL USE Application is Approved/Not Approved Signature Date Name and Designation of Approving Officer Delete as appropriate Page 1 of 1 Aviva Ltd 4 Shenton W ay 01-01 SGX Centre 2 Singapore 068807 Tel 65 6827 7988 Fax 65 6827 7900 www. aviva-singapore. com*sg Company Reg* No* 196900499K GST Reg* No* MR-8500166-8 Navigator Investment Services Ltd Company Reg* No* 200103470W GST Reg* No* 20-0103470-W.