New Report Request

Please complete all required fields. This process takes approximately 5 minutes.

Patient Info

Request Details

Applicant Info

Documents

Step 1 of 4

Patient Information

Enter the patient's personal details exactly as on their NRIC or Passport.

Full Name (as per NRIC/Passport) *

Citizenship *

Malaysian Citizen Non-Citizen

NRIC Number * Format: YYMMDD-SS-NNNN

Date of Birth *

Contact Number *

Email Address * Payment link will be sent to this email.

Step 3 of 4

Applicant Information

Who is submitting this request?

Applicant Type *

Patient (Self)

The patient is submitting this request personally

Third Party

Family member or authorized representative

Step 4 of 4

Document Upload

Please upload clear supporting documents. Accepted formats: PDF, JPG, PNG (Maximum 5MB per file).

Consent Form *

The hospital requires an official consent form to release medical information. Please follow the steps below.

Download & Fill

Download the PDF form below. You need to print it, fill in the details, and sign it (or use a digital PDF editor).

Download Template

Upload Completed Form

Once the form is completed and signed, please upload it to the area below.

Click to upload or drag file here

Identity Card (Front) *

Click to upload or drag file
IC Front Image

Identity Card (Back) *

Click to upload or drag file
IC Back Image

Authorization Letter (Only for Third Party)

Click to upload or drag file
Authorization Letter

I have read and agree to the Personal Data Protection Act (PDPA) and consent to Assunta Hospital collecting, using, and disclosing my personal data for the purpose of processing this medical report request. I understand that my information will be handled in accordance with the PDPA 2010. *