[MY B2B] Allianz Care@Home Services for Infineon

Allianz Care@Home Services for Infineon

General Line (for enquiries only): business.my@speedoc.com, contact.my@speedoc.com, +6011 4166 1178

Part 1: Details of the Insured Employee/Dependent to Be Examined
Full Name (as per NRIC/Passport)*
NRIC/Passport No.*
Date of Birth*

DayMonthYear
Gender*
Contact Number*
Email Address
example@example.com
Relationship*

EmployeeSpouseChild
On-site visit address*

Address Line 1

Address Line 2

CityState / Province

Postal CodeCountry
Type of Request

DengueGastroenteritisCellulitisLower Respiratory Tract Infection (LRTI)Upper Respiratory Tract Infection (URTI)

Part 3: Doctor's Statement
Please indicate patient's symptoms and primary treatment received. Please provide doctor's name, MMC number and doctor's phone number.
Please attach referral letter issued by the Doctor (Optional):

Cancelof
Date

DayMonthYear
Date
Please verify that you are human*
Should be Empty: