Provider Application Form

Clinic / Hospital Name *

Provider Type *

Date Start Operation *

Company Name *

Company Registration No. *

UKAPS/CKAPS Registration No. *

Address Line 1 *

Address Line 2

City *

State *

Country *

Postcode *

Tel. No. *

Fax No. *

Email Address *

Name of Person In-Charged *

Person In-Charged Tel. No. *

Person In-Charged Email Address *

Name of Doctor In-Charged *

Doctor In-Charged MMC No. *

Doctor In-Charged Mobile No. *

Doctor In-Charged Email Address *

Services Provided *

Additional Facilities

Internet / Broadband

X-Ray Room

Open 24 hours

Operating Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Consultation Charges

Day Consultation *

From

SGD

Till

SGD

Night Consultation *

From

SGD

Till

SGD

Weekend/PH *

From

SGD

Till

SGD

Medication Charges for Treatments

URTI / Sore Throat *

From

SGD

Till

SGD

Cough / Cold *

From

SGD

Till

SGD

Bronchitis *

From

SGD

Till

SGD

Gastritis *

From

SGD

Till

SGD

Gastroentritis / Diarrhea *

From

SGD

Till

SGD

Fever *

From

SGD

Till

SGD

Vommitting *

From

SGD

Till

SGD

Headache / Migraine *

From

SGD

Till

SGD

Dermatitis / Skin Disorder *

From

SGD

Till

SGD

Backache / Bodyache *

From

SGD

Till

SGD

Burns & Scalds *

From

SGD

Till

SGD

Injury & Cuts *

From

SGD

Till

SGD

Asthma *

From

SGD

Till

SGD

Sinus *

From

SGD

Till

SGD

Abdominal Pain *

From

SGD

Till

SGD

Charges for Medical Procedures

X-Ray *

From

SGD

Till

SGD

Ultra Sound *

From

SGD

Till

SGD

Dressing *

From

SGD

Till

SGD

Nebulizer *

From

SGD

Till

SGD

Minor Surgery *

From

SGD

Till

SGD

Charges for Lab Test

Blood Test *

From

SGD

Till

SGD

Blood Sugar Level Test *

From

SGD

Till

SGD

Urine Test *

From

SGD

Till

SGD

Cholestrol *

From

SGD

Till

SGD

Charges for Dental Treatments

Scalling *

From

SGD

Till

SGD

Cleaning *

From

SGD

Till

SGD

Extraction *

From

SGD

Till

SGD

Anesthetics or Antibiotic *

From

SGD

Till

SGD

Fillings *

From

SGD

Till

SGD

X-Ray *

From

SGD

Till

SGD

Minor Surgery *

From

SGD

Till

SGD

Once your application is approved by our service provider selection committee, your facility will be added to our panel and a one-off appointment fee will be charged for processing and activation.