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CompuMed Panelship Application Form
Please fix the following errors:
Contact Details
Health Provider Name
Provider Type
-- Select --
Dental Clinic
Medical Clinic
Clinic Type
-- Select --
Outpatient GP
Specialist Clinic
Doctor Name
Phone
Fax
Email
Address Details
Address1
Address2
Address3/Township
Postcode
City
State
-- Select --
Johor Darul Takzim
Kedah Darul Aman
Kelantan Darul Naim
Melaka
Negeri Sembilan Darul Khusus
Pahang Darul Makmur
Perak Darul Ridzuan
Perlis Indera Kayangan
Pulau Pinang
Sabah
Sarawak
Selangor Darul Ehsan
Terengganu Darul Iman
Wilayah Persekutuan Kuala Lumpur
Wilayah Persekutuan Labuan
Wilayah Persekutuan Putrajaya
District
-- Select --
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Required Documents
Picture of Entrance
Picture of Reception
Picture of Waiting room
Picture of Consultation room
Picture from Street view with signboard
Important Notes
Please provide accurate information
Please provide decent quality pictures
Email address will be used as primary correspondence channel
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