Certificate of Cause of Death (CCOD)

Certificate of Cause of Death (CCOD)

Please enter the details below and our team will get back to you with a confirmation soon.

CALLER DETAILS
Full Name*
Company / Organisation Name
Contact Number*
Email*
Appointment confirmation will be sent to this email
Location of CCOD Request*

Street Address

Floor, Unit #, Ward #, Bed #, Building Name etc.

CityState / Province

Postal CodeCountry

PATIENT DETAILS
Full Name (as in NRIC)*
NRIC/FIN/Passport No.*
Nationality*
Gender*
Date of Birth*

DayMonthYear
Expected Reason of Death*
Pacemaker Removal*
Catheter Removal*

BILLING DETAILS
Bill to*

Company / OrganisationNext of KinOther
Next of Kin Name*
Contact Number*
Remarks / Special Instructions (optional)
TERMS AND CONDITIONS
1. Our team will contact you after you submit the request with the confirmed doctor name and time.
2. Please note the preferred times are subject to availability. Speedoc will try its best to allot the time selected, but due to high demand may offer a different appointment time.
3. Please have the NRIC/FIN or Passport Number of the deceased ready for the appointment.
4. These form is not suitable in the case of an emergency. Please call 995 in that instance.
5. A $54 surcharge applies for any scheduled Doctor Home Visit from 8pm to 8am.
6. A $64.80 surcharge applies for any scheduled Doctor Home Visit on a Public Holiday.
7. A $32.40 surcharge applies for any scheduled Nurse Home Visit from 8pm to 8am.
8. A $43.20 surcharge applies for any scheduled Nurse Home Visit on a Public Holiday.
9. An island surcharge of $43.20 will apply for any scheduled doctor visits to Sentosa, Jurong Island and Tuas.
10. An island surcharge of $43.20 will apply for any scheduled nurse home visits to Sentosa, Jurong Island and Tuas.
*

I agree to the above Terms and Conditions
Please verify that you are human*
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