Medivac House Call Doctor Form House Call Doctor 12345 PART I: Client InformationOrder Number (Hidden)This field is hidden when viewing the formOrder Number(Required)Client Name(Required)ID Number [ As per NRIC or Passport Number ](Required)Address [ As per NRIC ](Required) Street Name Unit Number Postal Code Email(Required) Mobile Number(Required) PART II: Verify Your IdentityVerify Your Identity(Required) Identity Document Select Your Document Type(Required) Passport ID Card Singpass Upload of Client ID [ Front ](Required) Drop files here or Select files Max. file size: 10 MB, Max. files: 1. Upload of Client ID [ Back ] Drop files here or Select files Max. file size: 10 MB, Max. files: 1. PART III: Product InformationThe Standard Waiting Time : 1 - 3 hoursWhat Happen to The Patient ?(Required)Location / Address of Patient(Required) Same as NRIC Street Name Unit Number Postal Code House Call Doctor(Required) Price: PART IV: Your Total BillHouse Call DoctorProduct(Required)Your Estimate BillYour Estimate Bill(Required) PART V: Financial Counselling for House Call Doctor To: MEDIVAC EMERGENCY AMBULANCE SERVICE P/L 202320939D FINANCIAL COUNSELLING FOR HOUSE CALL DOCTOR This is to confirm that I: had been informed that : - The one time consultation fee for the house call doctor is : S$ 450 for General practitioner S$ 550 for Emergency Medicine Specialist This excludes investigations , medication and supplies used. There shall be no cancellation , for whatever reasons , once confirmed and the waiting time for the doctor is approximately 45 mins to 3 hours. Payment of service shall be made immediately upon delivery of service through Bank transfer (i.e. Paynow). This Agreement shall be deemed to be made under and governed by the laws of the Republic of Singapore in all respects, including matters of construction, validity, and performance. *Note : The parties agree that to the extent they sign electronically, their electronic signature is the legally binding equivalent to their handwritten signature.Signed and Agreed By :I Agree I Agree Full Name [As per ID](Required)Signature(Required)
