Guarantee Letter Application

Apply for your Guarantee Letter ahead of your appointment to save time.
We'll process your application and get the GL ready before your visit.

Please fill this form up together with the required attachment. Once submitted, we will process and be in touch with you. We are continuously improving our digital journey experience for you, so please suggest feedbacks to better improve our services.

Patient Information

Title:^*

Name :^*

NRIC :^*

Contact Number :^*

Please upload the front of NRIC for registration:^*

Please upload the back of NRIC for registration:^*

Email :^*

Date of Birth :^*

Gender :^*

Insurance / Company Name :
_{(It is advisable for patient to upload the image of your Medical Card copy in the supporting document field.)}

GL Recipient :

Requestor Information

Name:

NRIC:

Email:

Contact Number:

Membership Number:

Appointment details

Have you made an appointment:

Yes

Select Doctor's Name^*
Select Date^*

There is no appointment found. Click here if you wish to set a appointment

Select a specialty: ^*

Do you know the sub-specialty?^*

Yes

Select Sub-specialty:

Select Doctor's Name^*
Please select appointment date^*
Please select appointment time :

Please upload your Referral Letter / Guarantee Letter / Medical Card or any other supporting documents

File 1

File 2

File 3

Note: PDF, PNG, JPG formats are supported. File limit 5MB.

By submitting this Form, you hereby agree that KPJ Selangor Specialist Hospital may collect, use and disclose your personal data as provided in this Form,
for the following purposes in accordance with the Personal Data Protection Act 2010 and our data protection policy.
Please visit our website at https://kpjhealth.com.my/selangor/pdpa for further details on our data protection policy.

Guarantee Letter Application

Patient Information

Requestor Information

Appointment details

Please upload your Referral Letter / Guarantee Letter / Medical Card or any other supporting documents

× Application Submitted

× Application Error

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