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Jenis maklum balas

Pujian

Cadangan

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Pilih satu Pilihan

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Tarikh Lawatan*

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Nama pertama*

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Nama akhir*

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Gelaran

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Alamat Emel**

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Kewarganegaraan

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Eg: +60**

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Nombor untuk Dihubungi*

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Pilih Hospital

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Nombor Rekod Perubatan (MRN)

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Mesej*

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Would you like us to contact you about your feedback?

Yes

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*Medan perlu diisi

*Dengan menyerahkan borang ini, saya mengakui bahawa data yang diberikan adalah tertakluk kepada Notis Perlindungan Data Peribadi IHH MY

Saya bersetuju menerima mesej atau cagaran berkaitan pemasaran.

Saya tidak bersetuju menerima mesej atau cagaran berkaitan pemasaran.

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Hantar

By providing the information set out in this form, I consent to Gleneagles Hospitals Sdn Bhd (GLENEAGLES) and their representatives and/or agents collecting, using and disclosing my personal data to provide me with medical treatment and other reasonably related purposes. Such purposes are set out in the GLENEAGLES Data Privacy Policy or available on request. I further confirm that all personal data that I have provided are all true, up-to-date and accurate. Should there be any changes to any of my personal data, I shall notify GLENEAGLES immediately.

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