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Maklumat Pesakit Patient Details Nama Penuh (seperti IC): _____________________________________________________ Full Name (as per IC) No. NRIC/Passport: _____________________________________________________ NRIC/Passport No. Email: _____________________________________________________ No. HP/Mobile: _____________________________________________________ Saya mengesahkan maklumat yang disampaikan dalam borang ini adalah benar dan tepat. Saya membenarkan Healthcare Optimisation Partners Sdn. Bhd. (“HOP”) dan mana-mana pihak ketiga yang terbabit dengan apa-apa rawatan dan penjagaan kesihatan saya untuk memperoleh dan memproses Data Peribadi yang disampaikan, tertakluk kepada Notis Privasi HOP, polisi syarikat, amalan perubatan, dan rang undang-undang yang berkenaan. Saya setuju dan memahami bahawa kebenaran ini berkuatkuasa selagi tidak ditarik balik. HOP menghargai privasi anda dan kami sentiasa berusaha untuk menjaga maklumat peribadi anda ("Data Peribadi") menurut Akta Perlindungan Data Peribadi 2010. Sila rujuk laman web kami di www.hopQ.me untuk Notis Privasi dan Terma dan Syarat selengkapnya. I hereby declare that the information given above is true and accurate. I also consent to allow Healthcare Optimisation Partners Sdn. Bhd. (“HOP”) and any third parties who are involved in my treatment and care, to access and process the above-mentioned Personal Data in accordance with HOP's Privacy Notice, internal policies, practices and relevant laws. I understand that this consent is for all visits and will be good until the consent is withdrawn. HOP values your privacy and strives to protect your personal information or “Personal Data” in accordance with the Malaysian Data Protection Act 2010. The complete Privacy Notice and Terms and Conditions of the hopQ service are available on www.hopq.me

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Maklumat Doktor yg Merujuk Referring Doctor’s details Nama Penuh: _____________________________________________________ Full name Pakar/Pegawai Perubatan (bulatkan yg berkenaan) SP / MO Specialist/Medical Officer (circle as appropriate) Jika Pegawai Perubatan, sila nyatakan nama Pakar: ________________________________________ If MO, please state name of attending Consultant/Specialist Bidang Kepakaran/Jabatan: _____________________________________________________ Medical Speciality/Department Nama Hospital KKM: _____________________________________________________ KKM Hospital Name Email: _____________________________________________________ No. HP/Mobile: ____________________________________________ No. Pendaftaran MMC: _________________________________________ MMC Registration No. No. Pendaftaran NSR (jika berkenaan): ______________________________________ NSR Application No. (if applicable) Tandatangan dan Chop Doktor Pakar: _____________________________________________________ Signature and Stamp of Consultant/Specialist

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*FIELDS ARE MANDATORY Imaging Referral Information: Tick ( Ö ) where appropriate Imaging Type* [ ] CT [ ] MRI Imaging Procedure* (e.g. CT Brain): _____________________________________________________ Modifier* (e.g. Left, Right, Both): ______________________________________________________ Contrast*: [ ] Yes [ ] No Pregnant (if applicable): [ ] Yes [ ] No Ambulatory*: [ ] Yes [ ] No Menopause (if applicable): [ ] Yes [ ] No

Last Menstruation Period (if Applicable): __________________________

Kidney Function Test (mandatory if with contrast, within 3 months of scan appt) Date of Test: _________________________________ Result: _________________________________ Medical History and Reason for Examination*: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Special instructions (if applicable): _________________________________________________________________________________________________ _________________________________________________________________________________________________

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