1. This form must be fully completed and signed by the patient. If patient is below 18 years old, the form should be signed by the parents/guardian.
2. If patient is deceased or unable to give consent, consent is required from the appointed representative of the estate.
3. Photocopies of the relevant documents e.g. birth certificate, death certificate, marriage certificate are to be attached as proof of relationship to the patient if applicable.
4. Patient has to enclose a photocopy of own ID card (HMO/work) if submitting via mail, fax or email.
5. The completed form must be submitted with payment of fee if applicable.
6. The release of the medical information is subject to official approval.
7. Medical report processing takes approximately a week from the date of submission.
NB: Kindly note that SSWCH is under an obligation to give full and factual disclosure of all material facts relating to your medical condition as required to be notified to the relevant health authorities.
Besides the medical report fee, I undertake to pay any additional charges such as x-ray and lab investigation charges that may be incurred in the preparation of the report. I am also aware that there will be a cancellation charge of 1/2 of the medical report fee should I decide to cancel this request.
With Hospital Number
hereby authorize SSWCH to furnish and release below stated:
I hereby declare and confirm that I have been given adequate explanation on the contents of this form, which has been fully explained to me, and fully understand by same. The information given above is accurate to the best of my knowledge, and that the requisite information is required for the sole purpose stated above. I understand that I may be liable for prosecution for making false declaration. Further, I confirm that I shall not hold SSWCH or any of its employees, servants or agents responsible in any way whatsoever for the release of the said medical information to any party by me in the event from any loss or damage arising directly or indirectly as a result or in connection with the release of such confidential information. By reason of the aforesaid, I undertake full responsibility and liability arising from the release of the requested information.