IHH Marketing Leads

Where the lead came from and which IHH hospital is preferred.

Preferred Hospital

Identifying information for the patient receiving care.

Patient's Full Name

Patient's Gender

Female Male

Patient's Date Of Birth

Patient's Nationality

Patient's Passport Number / NRIC

Patient's Email Address

Patient's Contact Number

Patient's Alternative Contact Number

Type of visit and any preferences.

Appointment Type

Specialist Appointment Health Screening Appointment Vaccination Appointment

Medical Conditions or Health Screening Package

Specialty (N/A if unsure)

Preferred Doctor (N/A if no preferred Dr)

Preferred Appointment Date (Option 1)

Preferred Appointment Time (Option 1)

Preferred Appointment Date (Option 2)

Preferred Appointment Time (Option 2)

May we contact the patient with relevant updates from IHH Healthcare?

Patient agrees to receive marketing-related messages or collaterals

Yes No