Please attach
your photo
here
Friends-of-Diagnostics Membership Application Form
Name in full (please underline surname):
MCR No.:
NRIC/Passport No.:
Date of Birth:
Gender:
Nationality:
Race:
Marital Status:
Religion:
Male
/
Female
Mobile No. (for SMS Purpose):
Email Address:
 I do not wish to receive email on NHGD CME events.
Locum Status:
Yes / No
Basic Qualifications:
Post-graduate Qualifications: Masters of Medicine (Family Medicine) / Graduate Diploma in Family Medicine
Others (please state):
Your clinic’s specialisation(s)
 Aesthetics
 Hand & Reconstructive Surgery
 Anaesthesia
 Infectious Medicine
 Cardiology
 Neonatology
 Chronic Diseases
 Nephrology
 Dermatology
 Neurology
 Diagnostics
 Neurosurgery
 Emergency (A&E)
 Nutrition & Dietetics
 Endocrinology
 Obstetrics & Gynaecology
 ENT-Otolaryngology (Ear, Nose, Throat)  Oncology
 Family Medicine
 Ophthalmology
 Gastroenterology
 Orthopaedic Surgery
 Geriatrics
 Paediatric/ Paediatric Surgery
 Palliative Medicine
 Psychiatry - Adult
 Psychiatry - Child Adolescence
 Psychiatry - Psychogeriatric
 Rehabilitation
 Respiratory
 Rheumatology, Allergy & Immunology
 Sports Medicine
 Surgery
 Urology
 Weight Management
Hobbies:
Primary Clinic Name & Address:
Primary Clinic Tel:
Secondary Clinic Name & Address:
Fax:
Secondary Clinic Tel:
Primary Clinic Opening Hours:
Secondary Clinic Opening Hours:
Primary Clinic Assistants’ Names:
Secondary Clinic Assistants’ Names:
Fax:
Mailing Address (if different from Clinic Addresses):
Applicant’s Signature
Date of Application
Please send this completed form together with a recent colour passport-size photograph to:
NHG Diagnostics
GMTI Building, 6 Commonwealth Lane
Unit 02-03, Singapore 149547
Tel: 6496 6633
Fax: 6496 6625
Email: askNHGD@diagnostics.nhg.com.sg