Form

Antenatal Class 2023
Your Pregnancy Journey Begins Here

Date:
23 Sep 2023 (Saturday)

Time:
9:00am – 4:30pm

Venue:
Opero Hotel Southkey, Johor Bahru
Grand Florius Ballroom
(click for map)

Fee:
RM 60 per couple
Limited to 60 couples only!
Register by 18 Sep 2023!

Terms & Conditions

Please make sure that you are well and healthy to join this antenatal class
Wear comfortable attire for maternal fitness exercise
Fees must be made ahead of event and kindly attached payment proof in this registration form or you may send payment proof to Khai @ +6010-2126880.

A/C Name: REGENCY SPECIALIST HOSPITAL SDN BHD

Bank: OCBC Bank (Malaysia) Berhad

Bank A/C No: 735 111 3824

Reference : RSH Antenatal 2023

Fees must be made ahead of event and kindly attached payment proof in this registration form OR you may send payment proof to Khai @ +6010-2126880.

Personal Information

How many weeks pregnant are you?*

Salutation*

Full name*

IC/Passport Number*

What ID did you enter?*

NRIC

Passport No (for international visitors)

Date of birth*

Day/Month/Year

Gender*

Email*

Please use your individual email address and not a shared one.

Mobile number*

Please use your individual phone number and not a shared one.

Spouse Salutation

Spouse Name

Spouse Gender

Street address*

City*

State/Region*

Country/Region*

Postal code*

Please upload your proof of payment (bank transfer) here.
*File size (up to 100MB)
*Pdf, Image (JPEG,PNG, GIF, etc)*

Do you have any other personal health concerns that you would like to consult with us on in relation to your pregnancy?

Are you planning to deliver your baby at Regency Specialist Hospital?*

Yes

Maybe

Data Protection & Privacy

I agree that Regency Specialist Hospital Sdn. Bhd., Health Management International Pte. Ltd. (“HMI”) and its group of companies (“HMI Medical”) may collect, use, disclose, retain or otherwise process my personal data which I have provided in this form, for the purposes of providing me with marketing, advertising and promotional material in accordance with this form, the Personal Data Protection Acts of Singapore (2012) and Malaysia (2010) respectively, and your Data Protection Policy.

I also consent to you disclosing my personal data to third-party service providers and their representatives for them to process my personal data for such purposes.

I understand that I may access and correct my personal data, or withdraw my consent at any time, by submitting a request via the channels listed in your Data Protection Policy.

Indemnification

I agree to the following event terms and conditions.*

I understand that the participation of this activity is voluntary.
I understand and acknowledge that there are risks and hazards inherent in the very nature of this Activity and as a result of the participation in this Activity. I have full knowledge of the nature and extent of these risks and acknowledge that, by participating in this Activity, I/the participant may suffer personal injury, death, property damage, loss, delay, inconvenience and the cancellation or early termination of this Activity, which injuries and losses are inherent in all activities of this nature.
In consideration of the participation of this Activity with its inherent risks and hazards, I understand that Regency Specialist Hospital Sdn. Bhd. does not provide any insurance coverage for my/his/her participation in this Activity. I am aware that I/the participant am/is fully and personally responsible for my/his/her own safety and actions while and during my/his/her participation in this Activity. In the event of illness or in case of an emergency, a responsible adult may transport me/the participant to a local clinic or hospital for treatment and that I agree to assume financial responsibility for any injury and/or damage suffered resulting from my/the participant’s participation in this Activity.
I agree to waive any and all claims for personal injury, death, property damage or loss that I/the participant may have now or in the future against Regency Specialist Hospital Sdn. Bhd., its employees, agents, volunteers, representatives, independent contractors or any of them, in connection with this Activity.
I agree to indemnify and hold harmless Regency Specialist Hospital Sdn. Bhd., its employees, agents, volunteers, representatives, independent contractors or any of them, from any and all claims, demands, expenses, costs (including legal costs), suits, debts, liabilities and cause of action for which it/they may become liable as a result of any personal injury, death, loss or property damage resulting from, occasioned to or suffered by any person or property as a result of any act or omission of mine/him/her in connection with my/the participant’s participation in this Activity.
I freely and voluntarily consent to the participation of myself/the participant in this Activity and agree to accept these risks and fully understand that I/the participant will be solely responsible for any loss, injury or damage sustained during this Activity.