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Full name

Office number

Mobile number

Clinic name

Clinic address

By providing the information set out in this form, I consent to IHH Healthcare Singapore and their representatives and/or agents collecting, using and disclosing my personal data to provide me with medical treatment and other reasonably related purposes. Such purposes are set out in the IHH Healthcare Singapore Data Protection Notice.

I also consent to IHH Healthcare Singapore, their representatives, agents and/or business partners collecting, using and disclosing my personal data for marketing and promotional purposes (described as "Additional Purposes" in the IHH Healthcare Singapore Data Protection Notice). I agree to receiving marketing messages via SMS, telephone call and other Singapore phone number-based messaging, regardless of my registration with the Do-Not-Call registry.

I understand that I may withdraw such consent at any time via unsubscribe facilities OR forms available on request from our staff OR by email to IHH Healthcare Singapore DPO.