Dear Doctors,

1. Thank you for your interest to join KCRh1n1 as a participating Clinic.
2. You can only join KCRh1n1 if you are a registered medical practitioner in private clinic, private hospital, statutory bodies, GLC or armforces etc.
3. Please provide us the required details by filling up the form below.
4. You are required to agree with the terms of participation in order to join as a participating clinic of KCRh1n1.
5. This is a nationwide campaign. The interest from Clinics have been overwhelming since we launch our Campaign on 20.8.2009. Please bear with us if we are not able to attend to you immediately, our representative will contact you at the soonest possible to assist you in the application.
6. Please use this form for submitting your request to Join KCRh1n1 only. If you need to contact us on other matters, please use the forms at the CONTACT US section.

Thank You.

Please fill in your details:

Clinic Name: *

Clinic Address1: *

Clinic Address2:

City: *

Postcode: *

State: * select...JohorKedahKelantanMelakaNegeri SembilanPahangPerakPulau PinangPerlisSabahSarawakSelangorTerengganuWilayah Persekutuan KLWilayah Persekutuan LabuanWilayah Persekutuan Putrajaya

Tel: *

Fax:

Business Hour:

E-mail address: *

Contact Person: *

Mobile:

Message:

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