MESAS2U > Register New Clinic Account

Clinic Details

Basic Information

Email (Unique for each clinic) *

Password *

Confirm Password *

Clinic Name *

Branch *

Company Name

Clinic Registration No (CKAPS) *

Commencement Year

Operating 24 Hour *

Operation Days Per Week

Owner (Pemegang Perakuan Pendaftaran in Borang B/F)

Type of Practice *

Type of Services

Company Registration Number (for sendirian berhad / Limited Liability Company)

Please Specify:

Website

Latitude

Longitude

Shipping Address (Must be same with Borang B or Borang F)

Address 1 *

Address 2 *

Address 3

Postcode *

Town *

State *

District

Person-in-Charge

Name *

NRIC (Do not enter any "-") *

Gender *

Male Female

MMC Registration No.

APC Number

Phone Landline *

Mobile No.

Fax No.

Signature of Person in Charge *

Clear

Qualification *

Clinic Administrator

Admin Name

Admin NRIC

Admin Email

Admin Contact No.

Section B: Electronic Health Records

Do you have a TPA currently (KOOP MMA is also looking at this possibility in the future):

Yes No

Does the clinic use clinical information/management system?

Document Upload

Certificate of registration to operate private medical clinic (Borang B or Borang F) *

Drop files here or click to upload.

remove

MMC full registration certificate of person-in-charge *

Drop files here or click to upload.

remove

Current annual practising certificate (APC) of person-in-charge (APC 2019) *

Drop files here or click to upload.

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PERKESO Program - Program Pemandu Sihat dan Selamat (PSS)

Onboard to PERKESO Program - Program Pemandu Sihat dan Selamat (PSS)?

Acceptance of Terms of Service, Privacy Policy

I confirm that the following facilities are available in the clinic computer, telephone, internet, printer, scanner, and fax machine.

I confirm *

I declare that the information I have given on this form is true and complete and that I have not been convicted or found guilty of any criminal offence in any country.

I declare *

I accept and agree to be bound by the Mesas2u Terms of Service and Privacy Policy.

I agree *

I accept and agree to be bound by the PSS Terms and Conditions.

I agree *

Clinic Operating Day & Time

*

Day	Start Time	End Time

COVID-19 Testing Schedule

Add time slots for COVID-19 Test:

Day	Start Time	End Time	No. of People to Test

Use different time slots for PCR-Testing

Add time slots for PCR COVID-19 Test:

Day	Start Time	End Time	No. of people to test

Public Holiday Settings

Custom Public Holiday Settings:

Public Holiday	Start Date	End Date

Referral

Please enter the referral code here (If any)

Please enter the verification code shown in the box onto the green line below *