Scribd
Upload
2K views

CI 01 Cancer PDF

The doctor's statement form provides details about a patient's cancer diagnosis and treatment. It documents the patient's name and NRIC number. It requests information about the diagnosis including site/organ involved, histology, staging, and whether the cancer is invasive or localized. The form also asks if the cancer is associated with HIV/AIDS and gets the doctor's signature and date to certify the accuracy of the provided information.

Uploaded by

ANIS NAZREEN BT SODZIR -
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
2K views

CI 01 Cancer PDF

The doctor's statement form provides details about a patient's cancer diagnosis and treatment. It documents the patient's name and NRIC number. It requests information about the diagnosis including site/organ involved, histology, staging, and whether the cancer is invasive or localized. The form also asks if the cancer is associated with HIV/AIDS and gets the doctor's signature and date to certify the accuracy of the provided information.

Uploaded by

ANIS NAZREEN BT SODZIR -
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

CI-01 DOCTOR’S STATEMENT - CRITICAL ILLNESS - CANCER

MEDICAL REPORT TO BE COMPLETED BY THE ATTENDING PHYSICIAN/ SPECIALIST


(For any medical report fee incurred in completing this form, it will be borne by Person Covered)
CI-01
Name of Patient (Person Covered) New NRIC No.

- -

1 Diagnosis

(i) Please describe the full and exact diagnosis. (i)

(ii)
(ii) Date when the Cancer illness was FIRST
diagnosed?
/ / (dd/mm/yyyy)

2 (i) What was the site or organ involve? (i)

(ii) What was the precise histology of the tumour? (ii)

(iii) What was the staging of the tumour? (iii)


Please provide full details using appropriate
staging classification (e.g. TNM, Ann Arbor,
Duke's etc.)

(iv) It is classified as: (iv) borderline malignancy carcinoma in-situ

having low malignancy potential non-invasive

having high malignancy potential invasive

pre-malignant

(v) The disease was: (v) invasive to adjacent tissues completely localized
You may tick ( ) more than one.
involved regional lymph nodes

distant metastatic. If so, please give details

3 Is the Cancer associated with HIV or AIDS? Yes No

If "Yes", please state the date HIV was first diagnosed / detected.

/ / (dd/mm/yyyy)

DECLARATION: TO BE COMPLETED BY THE ATTENDING PHYSICIAN/ SPECIALIST

I, the undersigned, certify that I have examined the above Person Covered and all statement made and answers given are true and to the
best of my knowledge and belief.

Name:

Address:

Signature and Official Stamp


Date: / / (dd/mm/yyyy)

CLM-B40DSCI01-V00-022019-TAKAFUL
Great Eastern Takaful Berhad (916257-H)
Head Office: Menara Great Eastern 303 Jalan Ampang 50450 Kuala Lumpur
Page 1 of 1 4033321332
Telephone: +603 4259 8338 Fax: +603 4259 8808 mySalam CareLine: 1-300-888-938
E-mail: [email protected] Website: www.greateasterntakaful.com

You might also like