Innoquest Online Registration Form

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) MMC copy of ordering physicians
3) Account number (from invoice)
4) Details of practising entities (if need new address)

DOCTOR'S APPLICATION FORM
CHANNEL
LAB CODE
DATE

MonthDayYear
Date
KAM NAME
KAM CODE
KAM Email Address
Current Customer No
See example below
Billing Code (Optional)
Do you wish to use a different practise address?

No, use the same addressYes, I have a new practise address
Physician's Details
Title
DR/DATO/DATIN/MR/MRS
Physician Name*
MMC No
Specialisation
Please Upload Your MMC Copy

Cancelof
Please Upload NRIC 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.

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
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

Acknowledgment
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.
Let Us Know Your Name (Requestor)*
Email Address (Requestor)*
example@example.com
Should be Empty:

DOCTOR'S APPLICATION FORM