[MY B2B] Allianz Health Day

Allianz Health Day - On-site Vaccination Pre-register Form
Full Name as per IC :*
Contact Number:*
Email Address:*
Vaccine Selection:*

Influenza: Vaxigrip Tetra (RM75 nett)Typhoid: Typhim (RM90 nett)
Important notes:
- Influenza: Recommend yearly vaccination.
- Typhoid: Recommend for revaccination every 2-3 years.
- Payment can be accepted via credit card/debit card on-site or via QR Pay.
- Be on time for your on-site vaccination.
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All personal data collected will only be utilized for this health screening and subject to provisions in Personal Data Protection Act Malaysia 2010
Please verify that you are human*
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Allianz Health Day - On-site Vaccination Pre-register Form