Clinic Portal > Register New Clinic Account

CLINIC REGISTRATION

Basic Information

Email (Unique for each clinic) *

Password *

Confirm Password *

Clinic Name *

Clinic Phone No. *

Select HQ or Branch *

HQ Branch

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) *

Website

Latitude *

Longitude *

How to obtain your Clinic's Latitude and Longitude using Google Maps.

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?

Doctor's Information

Doctors In-Charge:
(Add Doctor Name & Signature here) *

	Name	Full Registration No.

Document Upload

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

Drop files here or click to upload.

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MMC full registration certificate of person-in-charge *

Drop files here or click to upload.

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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)?

Bank Information

Bank Name: *

Bank Branch: *

Account Number: *

Account Name: *

Bank Information

Bank Name: *

Bank Branch: *

Account Number: *

Account Name: *

Attach Borang Maklumat Pembekal: *

Drop files here or click to upload.

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Download Borang Maklumat Pembekal | Panduan Mengisi Borang Maklumat Pembekal

Note: Clinic is required to attach the updated Borang Maklumat Pembekal & latest Bank Statement if there are changes in bank information.

Attach Latest Bank Statement: *

Drop files here or click to upload.

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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

Public Holiday Settings

Custom Holiday Settings:

Public Holiday	Start Date	End Date

Break Time

Lunch Start Time

Lunch End Time

Have dinner time?

Dinner Start Time *

Dinner End Time *

Referral

Please enter the referral code here (If any)

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