Vaccination Information System

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Health Declaration

Please fill out the following form in order to participate in our activity.

First Name

E-mail

NRIC / Passport No

Nationality

Last Name

Gender

Birthday

States

Have you been diagnosed with Covid-19? *

Yes

No

Please check all symptom that apply * Required

Loss of taste/smell

Body aches

Sore throat

Difficulty breathing

Cough

Runny nose

None of these

Are you currently taking any medication? *

Yes

No

Please let us know if you are currently ill.

Please provide any proof if you have a serious disease

Select File

Thanks for submitting!

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Vaccine Registration Form

Due to the Covid-19 pandemic, we have a variety of vaccinations available that we will schedule for you at any time that is convenient for you. Later we will notice you in e-mail.

medic pro

medicprousm@gmail.com

Contact Us : +04-300 6268

Monday - Friday 8:00 am - 6:00 pm
Saturday 9:00 am - 7:00 pm
Sunday Closed

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