Innoquest Online Registration Form

Sign Up With Us

Get access to our medical laboratory service with a comprehensive test menu. You can now expect more comprehensive testing abilities, state-of-the-art IT support systems, and an extensive global network of medical expertise.

Begin by registering through our online doctor's and credit application form. Here is the list of supporting documents required to complete your registration:

1) Details of ordering physicians
2) Details of practising entities
3) MMC copy of ordering physicians
4) Latest Doctor's Annual Practicing Certificate (APC) copy
5) Person In Charge/Director NRIC copy
6) Company Documents as below:

Sdn Bhd: SSM Section 14 Superform (Form 24, Form 44, Form 49), SSM Section 15, SSM Section 17 (Form 9), Section 58

Partnership: LLP Form (PLT)

Sole Proprietorship: Form 15/ Form B
Register Your New Ordering Doctor

Get access to our medical laboratory service with a comprehensive test menu. You can now expect more comprehensive testing abilities, state-of-the-art IT support systems, and an extensive global network of medical expertise.

Begin by registering through our online doctor's application form. Here is the list of supporting documents required to complete your registration:

1) Details of ordering physicians
2) Details of practising entities
3) MMC copy of ordering physicians
4) Account number (from invoice)

DOCTOR'S APPLICATION FORM
CHANNEL
LAB CODE
DATE

MonthDayYear
Date
KAM NAME
KAM CODE
Add New Doctor Code to Existing Account?

YesNo
Current Customer No
Practise Details
Type of Practise*

HospitalClinicCorporate
Type of Clinic
Type of Corporate
Hospital/Clinic/Corporate Name*
Please write down your establishment name. E.g: Klinik Abu Bakar
Hospital/Clinic/Corporate Address Line 1*
Building/ Unit No, Building Name
Hospital/Clinic/Corporate Address Line 2
No, Street Name
Postcode (Click Search Postcode)*
Postcode
City
State Name
Your Weekday's Operation Hours
eg 8am - 9pm, mon to thursday, closed on friday
Your Weekend's Operation Hours
eg 8am - 12pm, saturday, closed on sunday
Contact Details
Mobile *

+60123456789
Phone 1

+60123456789
Phone 2 (Optional)
Fax
Email Address*
example@example.com

Physician's Details
Title
DR/DATO/DATIN/MR/MRS
Physician Name*
MMC No
Specialisation
Please Upload Your MMC Copy

Cancelof
*Disclaimer: Uploaded documents are used solely to process account opening application.
Panic Value
Contact Number for Panic Value*
Doctors signature*

Clear
Note: Acknowledge of acceptance in providing the contact number for reporting panic value.

CREDIT APPLICATION FORM
Registered Business Name*
Business Trade Name
If Different from Registered Business Name
Business Registration No
12-digits
Ownership Status*

Sole ProprietorshipPartnershipSdn Bhd or BhdLtd Liability Partnership (LLP)
Tax Identification No.*
Required for the government e-invoicing implementation
SST Registration No.
Protocol/Studies No
*For Sdn Bhd or Bhd, you are required to provide name and company details with latest copy of Form 9, Form 24 and Form 49 or Form 58, Dr APC & NRIC) (if different from Registered Business Name)
NRIC (director) copy*

Cancelof
Doctor's Annual Practicing Certificate (APC) copy*

Cancelof
Borang B or F (Akta Kemudahan dan Perkhidmatan Jagaan Kesihatan Swasta 1996)*

Cancelof
Form 24*

Cancelof
Form 9*

Cancelof
Form 49 / 58*

Cancelof
Protocol/Studies Supporting Documents

Cancelof
*Disclaimer: Uploaded documents are used solely to process account opening application.
Prefill using your Hospital/Clinic/Corporate address?

Yes
Business Address Line 1
Building/ Unit No, Building Name
Business Address Line 2
No, Street Name
Is your billing address different?

YesNo
Billing Address Line 1
Billing Address Line 2
Business Tel No*
Mobile No*
Name of Proprietors / Partners / Directors
Name of Proprietors / Partners / Directors 1*
IC No/Passport Proprietors / Partners / Directors 1*
Home Address Proprietors / Partners / Directors 1*
Name of Proprietors / Partners / Directors 2
IC No/Passport Proprietors / Partners / Directors 2
Home Address Proprietors / Partners / Directors 2
Name of Proprietors / Partners / Directors 3
IC No/Passport Proprietors / Partners / Directors 3
Home Address Proprietors / Partners / Directors 3
Account Details
Bank Name*
Account Holder Name*
Bank Address*
Account No*
Account Email
example@example.com
Person to contact for Payment / Account enquiry
Name (Person In Charge for Account enquiry)*
Designation*
Tel No (Person In Charge for Account enquiry)*
Person In Charge for Account enquiry email*
example@example.com
Fax No
Is the Person In Charge for Account enquiry address different?

YesNo
Person In Charge Address Line 1
Building/ Unit No, Building Name
Person In Charge Address Line 2
No, Street Name

Your Official Stamp*

Cancelof
**Authorised person must be a Director or Authorised Corporate Representative of the legal entity
Authorised Signature (Director)*

Clear
Date

DayMonthYear
Date
Name of Signatory (Director)*
Designation*
Terms and Conditions
1. Innoquest Pathology Sdn Bhd reserve the right to charge finance charges at 1.5% per month for any overdue invoices as per credit terms specified in the invoices.
2. Changes in any of the information above shold be updated using our Revision Form and re-submitted to us.
Acknowledgment
Customer Acknowledgement*

By providing the e-signature and submitting this online form, I hereby confirm that I am the authorised representative of the company applying for credit and agree to the terms and conditions set above. The information provided above is accurate, and complete for billing and operation purposes.
Consent to Share Collected Details*

We/ I consent for Innoquest Pathology to use and refer to my submitted document in order to proceed in processing the application to open an account with Innoquest Pathology Sdn. Bhd.
Opt-in to e-Newsletters, Latest Update and Promotions, Offers

I agree to opt-in to receive Innoquest's e-newsletters via email for latest updates and promotions, including offers from its associated companies and partners.
Should be Empty:

DOCTOR'S APPLICATION FORM

Practise Details

Contact Details

Physician's Details

Panic Value

Reporting Preference

Logistics Services (For Courier Superior to fill up)

To be completed by Marketing Coordinator

To be acknowledged by Manager/Director

CREDIT APPLICATION FORM

Name of Proprietors / Partners / Directors

Account Details

Person to contact for Payment / Account enquiry

Acknowledgment