NATIONAL UNIVERSITY HOSPITAL Patient Liaison Centre (PLC)

TELE-CONSULTATION APPOINTMENT REQUEST FORM

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Please fill in the details or place an “X” (where applicable) in the grey boxes as indicated below.

PATIENT INFORMATION
Name of Patient (as in passport):
Note: Please send us a copy of patient’s passport for verification. Information indicated with “*” may be left blank if
a copy of passport is provided in your reply email.
Email:
Tel No.:
Home Address:
Nationality*:
Date of Birth*:
Gender*: Female Male
Has patient been treated at NUH before? No Yes
NUH Registration No. (if avail):
Preferred Appointment Schedule (please Dates
provide a range): Session Morning Afternoon No Preference
Current Medical 1 (most important)
st

Condition; 2nd
Diagnosis; Signs
&/or Symptoms 3 (least important)
rd

IMPORTANT NOTES

o The medical opinion given by the NUH doctor during a teleconsultation is based on verbal information and
medical report and/or investigation results (if any) as provided by the patient, and in the absence of a
physical examination by the NUH doctor on the patient.

o This medical opinion is based on the practice of medicine from a Singapore point of view.

o NUH recommends that an in-person consultation with our doctor in Singapore, or a local doctor in the home
country, remains the preferred mode for patient to seek medical advice.

PLC Helpline: +65 6779-2777 ♣ Fax: +65 6777-8065 ♣ Email: plc@nuhs.edu.sg BDU-FORM-GEN-011(R0-03-21)