[MY] Flu Vaccination Booking

Flu Vaccination

Receive timely vaccinations to protect you and your loved ones from the seasonal flu.
Kindly refer to the appended section below before proceeding

If you have any of the following symptoms or medical conditions, please consult a doctor before making an appointment for the influenza vaccination:
- Allergies to egg/egg proteins
- Previous instance(s) of severe or life-threatening allergic reactions
- Previous instance(s) of allergies to other vaccines
- Have been diagnosed with Guillain-Barre Syndrome
- Are feeling unwell
I have read and understood the information/contraindications indicated above.*

I hereby declare that I do not have the above mentioned medical conditions and symptoms.I have one of the above mentioned medical condition/symptoms and I would like to consult with a Speedoc doctor.

Please select the number of people receiving the flu vaccination*

Influenza Vaccination

Note: For multiple pax bookings, vaccination will be carried out at a single household. Price reflected is inclusive of prevailing tax.

160.00MYR Quantity

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Total

0.00MYR

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
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APPOINTMENT DETAILS
Please select your preferred vaccination date and time.*
First Person
Full Name (as in NRIC)*
NRIC*
Nationality / Citizenship*
Gender*
Date of Birth*

DayMonthYear
Mobile Number*
Email*
Appointment confirmation will be sent to this email
Home Address*

Street Address

Floor, Unit #, Building Name etc.

CityState / Province

Postal CodeCountry
Second Person
Full Name (as in NRIC)*
NRIC*
Nationality / Citizenship*
Gender*
Date of Birth*

DayMonthYear
Third Person
Full Name (as in NRIC)*
NRIC*
Nationality / Citizenship*
Gender*
Date of Birth*

DayMonthYear
Fourth Person
Full Name (as in NRIC)*
NRIC*
Nationality / Citizenship*
Gender*
Date of Birth*

DayMonthYear
Fifth Person
Full Name (as in NRIC)*
NRIC*
Nationality / Citizenship*
Gender*
Date of Birth*

DayMonthYear
Remarks / Special Instructions (optional)
TERMS AND CONDITIONS
1. Speedoc Pte Ltd reserves the right to verify the validity of codes entered during the submission of this form.
2. A RM100.00 surcharge applies for any scheduled Doctor Home Visit on a Public Holiday and Weekends.
3. A RM50.00 surcharge applies for any scheduled Nurse Home Visit on a Public Holiday and Weekends.
4. An additional surcharge of RM50.00 may apply for visits to areas located 30KM-60KM from Klang Valley.
5. An additional surcharge of RM120.00 may apply for visits to areas located more than 60KM from Klang Valley.
6. Rates are not applicable with other on-going promotions, discounts, offers, vouchers, rebates or privileges.
7. Speedoc’s General Terms and Conditions of Service(s) can be found at https://my.speedoc.com/en/help/terms (“Terms of Use”) and may be amended from time to time.
8. For more information, contact our team at contact.my@speedoc.com or +601141661178.
I agree to the above Terms and Conditions.
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