ask@lifefamilyclinic.comAMK: 6456-3535 CCK: 6766-9119

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Life Family Clinic

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Appointment Form

General Information
Name*
Phone Number*
Email
Clinic Location*
- Ang Mo Kio
- Choa Chu Kang
Service*
- General consultation
- Health screening
- Aesthetics services
- Vaccination
- Pap Smear
Past History
Do you have hypertension?
- No
- Yes
Are you on medication for Hypertension?
- No
- Yes
Do you have Diabetes?
- No
- Yes
Are you on medication for Diabetes?
- No
- Yes
Do you have high Cholesterol?
- No
- Yes
Are you on medication for high Cholesterol?
- No
- Yes
Do you have Asthma?
- No
- Yes
Do you have any other medical problem(s)?
- No
- Yes
Please specify
Family History
Do you parents have Diabetes?
- No
- Yes
How many years?
Do you parents have high Cholesterol?
- No
- Yes
Do you parents have Hypertension?
- No
- Yes
Does any of you parents had Stroke?
- No
- Yes
Appointment Preferences
Doctor Preferences
- No preferences
- Female
- Male
Preferred appointment date*
Time

: HH

MM
Promo code

We Accept

Our Addresses

Ang Mo Kio

Blk 713 Unit 01-4052, Ang Mo Kio Avenue 6
Singapore 560713.
Phone: 6456 3535, SMS: 9820 4940

Choa Chu Kang

Choa Chu Kang Avenue 4 (CCK MRT), #01-28/29
Singapore 689610.
Phone: 6766 9119, Fax: 6766 2345

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