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Print Medical Examination Form-BADRUT TAMAM

The medical examination form is for a worker named Badrut Tamam who is undergoing a medical exam on February 6, 2024. The form provides key details about the worker such as their passport number, date of birth, gender, and employer information. It also lists the clinic, doctor, and laboratory conducting tests and states the medical exam results are valid until March 6, 2024. The form is signed by the examining doctor.

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AlexAhmad
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152 views

Print Medical Examination Form-BADRUT TAMAM

The medical examination form is for a worker named Badrut Tamam who is undergoing a medical exam on February 6, 2024. The form provides key details about the worker such as their passport number, date of birth, gender, and employer information. It also lists the clinic, doctor, and laboratory conducting tests and states the medical exam results are valid until March 6, 2024. The form is signed by the examining doctor.

Uploaded by

AlexAhmad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :

Examination Date
MEDICAL EXAMINATION FORM
Tandatangan Doktor :
Doctor's Signature

Sah Sehingga/ Valid Until: 06/03/2024 Cop Klinik :


Cancellation/ Refund before 06/03/2024 Clinic's Stamp

Kod Pekerja: W36B026697


Worker Code
Nama Pekerja: BADRUT TAMAM Tarikh Pendaftaran: 06-02-2024
Worker Name Date of Registration
3 NEW TESTS
No. Pasport: E4521186 Nama Majikan: AZZ SIRNA TRADING
Passport No. Employer Name
Negara: INDONESIA Kod Majikan: E16A005096
Country Employer Code
Jantina: MALE No. Telefon Doktor: 0389442377
Gender Doctor Telephone No.
Tarikh Lahir: 20-07-1997 No. Telefon X-Ray: 0389442377
Date of Birth X-Ray Telephone No.

Sah Sehingga/ Valid Until: 06/03/2024 3 NEW TESTS


Kod Doktor: D7EV000027 ID Trans: 20240206596472
Doctor's Code Trans ID
Nama Doktor: V THANDAVUTHABANI A/L K VELOO Kod Pekerja: W36B026697
Doctor Name Worker Code
Nama Klinik & KLINIK SELVA Nama Pekerja: BADRUT TAMAM
Alamat: 30G, JALAN HARMONI INDAH 1 Worker Name
Clinic Name & TAMAN HARMONI INDAH
No. Pasport: E4521186
Address 43200 BALAKONG SELANGOR
Passport No.
Jantina: MALE
Gender
Tandatangan Doktor :
Doctor's Signature
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan : 0196319531
Clinic's Stamp Examination Date Employer Contact No.

Sah Sehingga/ Valid Until: 06/03/2024 3 NEW TESTS


Kod Makmal: L2ED000005 Kod Doktor: D7EV000027
Laboratory's Code Doctor's Code
No Telefon: 0193386372 No Telefon: 0389442377
Telephone No. Telephone No. ID Trans: 20240206596472
Nama Makmal & DUNIA WELLNESS & Nama Klinik & KLINIK SELVA Trans ID
Alamat: LABORATORIES SDN BHD Alamat: 30G, JALAN HARMONI INDAH 1 Kod Perkerja: W36B026697
Laboratory's NO 30-2, JALAN TTDI GROVE Clinic Name & TAMAN HARMONI INDAH Worker's Code
Name & Address 1/1 Address 43200 BALAKONG SELANGOR
Nama Pekerja: BADRUT TAMAM
TAMAN TTDI GROVE
43000 KAJANG SELANGOR Worker's Name

No. Passport: E4521186


Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan:
Clinic's Stamp Examination Date

Sah Sehingga/ Valid Until: 06/03/2024

Kod X-Ray: X5EK000151 Kod Doktor: D7EV000027


X-Ray's Code Doctor's Code
No. Telefon: 0389442377 No Telefon: 0389442377
Telephone No. Telephone No. ID Trans: 20240206596472
Nama Fasiliti KLINIK SELVA Nama Klinik KLINIK SELVA Trans ID
X-Ray & Alamat: NO. 30G JALAN HARMONI & Alamat: 30G, JALAN HARMONI INDAH 1 Kod Pekerja: W36B026697
X-Ray's Facility INDAH 1 Clinic Name TAMAN HARMONI INDAH Worker's Code
Name & TAMAN HARMONI INDAH & Address 43200 BALAKONG SELANGOR
43200 BALAKONG SELANGOR Nama Pekerja: BADRUT TAMAM
Address Worker's Name

No. Pasport E4521186


Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan: 0196319531
Clinic's Stamp Examination Date Employer Contact No.
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