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be filled up. Put a tick (√) in the relevant checkbox □. Put a dash (-) in the column if the information is not available. The PET/CT scan will not be booked unless the form is properly filled up and all the required information is supplied. Fax completed request form to 03-83124377.Please call 03-83145501 for confirmation. Patient’s Name: I/C No : Date of Birth : Gender : Ethnic group : Age : Contact No : Address : City/Town : Postcode : State : Relevant medical history : □ N.

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