1. Personal Information / Maklumat Peribadi

Full Name (Mr / Mrs / Miss / Madam) / Nama Penuh

Address/Alamat

NRIC No/No Kad Pengenalan

Date of Birth/Tarikh Lahir

Age/Umur

Occupation /Pekerjaan:

Tel No/No. Tel

Email/E-mel

Sex/Jantina

MaleFemale

Marital Status/Taraf Perkahwinan

Single/BujangMarried/BerkahwinWidower /Duda

Nationality / Warganegara

Race / Bangsa

Next of Kin / Waris

Tel No. / No. Tel

Vascular Access :

AV FistulaAV GraftOthersNil

2. Details of Employment / Maklumat Pekerjaan

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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]

Bersetuju membayar kos rawatan sebanyak RM90 tunai bagi setiap rawatan hemodialisis dengan mengemukakan wang pendahuluan RM270 setiap awal minggu sehingga permohonan kemasukan tetap diluluskan oleh Yayasan Buah Pinggang Kebangsaan Malaysia. (Agree to pay RM90 cash for each haemodialysis treatment by submitting advance payment of RM270 at the beginning of each week until the application for permanent admission is approved by the National Kidney Foundation of Malaysia)Mengemukakan laporan perubatan (submit medical report)Laporan ujian makmal yang lengkap dan terkini bagi ujian Hepatitis B, Hepatitis C dan HIV (Complete and most recent laboratory test reports for Hepatitis B, Hepatitis C and HIV)Borang Maklumat Keluarga (Family Information form)Salinan slip gaji dan borang Cukai Pendapatan terkini bagi pemohon dan semua ahli keluarga yang bekerja (A copy of the latest pay slip and income tax returns of applicant and all family members who are working)Salinan penyata KWSP terkini pemohon dan semua ahli keluarga yang bekerja (A copy of the latest EPF statement of applicant and all family members who are working)Salinan slip bayaran terkini dari Jabatan Pencen PERKESO (jika ada) bagi pemohon (A copy of the latest payment slip from the Pensions Department Social Security Organisation (SOCSO) (if any) for applicant;Salinan penyata akaun tetap atau simpanan (jika ada) bagi pemohon dan semua ahli keluarga yang bekerja (Copies of fixed deposits or savings accounts (if any) of applicant and all family members who are working)Bil elektrik, air, telefon & Astro (electricity, water, telephone and Astro bills)Gambar rumah pesakit (photos of patient’s house)Surat jaminan daripada majikan - tertakluk kepada terma dan syarat (Letter of guarantee from the employer -subject to terms and conditions)

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.