Corporate Registrationgoodclinic_acceso2026-04-23T04:46:05+08:00 Corporate Panel Application Form A G O O D clinic Entity Profiles Section 1: Company Information Company Name: Business Registration No: Industry: Company Telephone: Number of Employees: Company Address: Section 2: HR / Contact Person Name: Department: Designation: Contact Number: Mobile Number: Email: Medical Coverage Section 3: Facilities & Services (Please tick one option per row) Service Selection General Medical Treatment Yes No Call HR Minor Surgery Yes No Call HR Laboratory / Urine Tests Yes No Call HR ECG Yes No Call HR X-Ray (Referral) Yes No Call HR Ultrasound (Referral) Yes No Call HR Vaccination / Immunisation Yes No Call HR Pre-Employment Medical Yes No Call HR Chronic Illness Management Yes No Call HR Yes No Call HR + Add More Services Access & Eligibility Rules Section 4: Employee Identification Method (Select ONE) Name List Provided Company Authorisation Letter / Card Staff ID / Company Pass Clinic Attendance Slip Others: Section 5: Eligibility of Coverage (Select as applicable) Coverage Type Selection Employees Only Yes No Family Members (All) No Yes Family (Management Only) No Yes Financials & Legal Policy Section 6: Cost Control Settings (Select ONE primary option) Charge according to AGC Clinic rates Limit per visit to RM... Call HR if cost exceeds RM... Specify RM Amount: Section 7: Billing & Payment Terms Billing will be done monthly. Payment terms: 30 days from invoice date. Consultation fixed at RM15 only. Section 8: Terms & Conditions Consultation is fixed at RM15.00 only. Payment terms are 30 days from invoice date. Termination requires 14 days written notice. testing second testing Authorization & Sign-off Section 9: Agreement & Authorisation By signing below, the company agrees to appoint AGC Clinic as its corporate panel clinic under the agreed terms. I confirm the above appointment. Section 10: Authorised Signatory Name: Designation: Company: Date: Signature: Clear Signature Account Setup Create your login password to access your company dashboard after approval. Password: * Confirm Password: * Your username will be your Business Registration No. Use this together with your password to log in after your account is activated.
