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PERJANJIAN BAGI KEMASUKAN SEMENTARA KE PROGRAM HEMODIALISIS
YAYASAN BUAH PINGGANG KEBANGSAAN MALAYSIA (NKF)
AGREEMENT FOR TEMPORARY ADMISSION TO THE HAEMODIALYSIS PROGRAMME OF THE NATIONAL KIDNEY FOUNDATION OF MALAYSIA (NKF)

Adalah saya No K.P: mewakili diri saya / pesakit bernama
No K.P bersetuju dirawat sebagai pesakit sementara di Pusat Dialisis untuk suatu tempoh
masa tertentu atau sehingga permohonan kemasukan tetap saya / pesakit diluluskan oleh Yayasan Buah Pinggang Kebangsaan Malaysia, dan akan mematuhi syarat - syarat berikut:

I I.C No: representing myself / patient named
I.C No hereby agree that I/he/she will be treated as a temporary patient at Dialysis Centre for a certain period of time until my / patient’s application for permanent admission is approved by the National Kidney Foundation of Malaysia, and will comply with the following requirements:

 

[Tandakan Yang Berkaitan]/ [Tick Where Relevant]


Saya faham bahawa semua dokumen yang tersebut di atas diperlukan untuk pemprosesan kemasukan tetap ke Program Hemodialisis NKF dan permohonan subsidi Kementerian Kesihatan Malaysia. Jika saya gagal mematuhi syarat - syarat di atas atau gagal mengemukakan dokumen yang berkaitan dalam tempoh [4] empat minggu dari tarikh perjanjian ini, NKF berhak memberhentikan rawatan kepada saya / pesakit tanpa sebarang notis.

I understand that all the above-mentioned documents are required for the processing of my/ patient’s application for admission to the NKF Haemodialysis programme and the Ministry of Health subsidy for dialysis treatment. If I fail to comply with the conditions above or fail to submit the relevant documents within [4] four weeks of the date of this agreement, NKF reserves the right to discontinue treatment to me / patient without prior notice.






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