Outpatient Repeat Medication Service

☑ Yes, I would like to opt in to this Outpatient Repeat Medication Service and I agree to abide by the
terms and condition for this service Initials: Date:
I would like to opt out from this outpatient repeat medication service. Initials: Date:

Name ALFIAN BATUBARA

NRIC No/Passport NoX853198 MRN 0000968364
Phone (H)
Phone (O)
Mobile 62 813 6154 0880
* Home Address: KOMP. TASBI 2 BLOK 2 NO.14, MEDAN

* Delivery Address: KOMPLEK CITRA GARDEN RICH MANSION BLOK C 16

KELURAHAN TITI RANTAI, KECAMATAN MEDAN BARU
MEDAN, SUMATERA UTARA 20157
* Email address: i) batubaracindy@gmail.com
ii)

*Kindly provide email addresses (max of 2) that you will use to send your emailed request to Sunway Medical
Centre to engage the outpatient repeat medication service. In the event your email address, home or delivery
address has changed at any point of time, please inform our friendly pharmacy staffs on an immediate basis.

General Consent Clause

I have read the Personal Data Protection Notice provided by Sunway Medical Centre, pursuant to section
7 of Personal Data Protection Act 2010 (www.sunwaymedical.com.my) which includes purposes for
which my personal data and sensitive personal data is collected/processed and classes of third parties to
whom Sunway Medical Centre may disclose my personal data to.

I hereby consent to Sunway Medical Centre to process my personal data and sensitive personal data in
accordance with the Personal Data Protection Notice.

ALFIAN BATUBARA 20 SEPTEMBER 2022

Signature Name in block letters Date
SMC-AH-PHAR-FORM003-VER002