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MediClub Platinum Membership Application Form

Be Rewarded for Looking After Your Health
Join now as a MediClub Platinum member and enjoy a host of exclusive benefits and rewards. Fields marked (*) are mandatory.

Personal Information

Name (as in IC or passport)*
MYKad No.*
Passport No. (Non-Malaysian)*
Date of Birth *
/ /
Gender*
Male Female
Marital status*
Single Married Others

Contact Information

Address *
(line 1)
  (line 2)
PostCode *
City *
State *
Country *
Email *
Tel (Handphone) *
Tel (Home) *
Tel (Office) *
Fax

Other Details

Occupation level:
Combined monthly household income
Which of the following newspaper do you read? (Tick one or more)
The Star
New Straits Times
Berita Harian
Utusan Malaysia
Sin Chew Jit Poh
Nanyang Siang Pau
others (Please specify)

Preferred interest (Tick one or more)
Anti-aging
Arthritis, Bone & Joint
Brain Health
Children's Health
Cold, Flu & Immunity
Energy
Everyday Health
Eye Health
Heart & Circulation
Liver & Digestive Health
Men's Health
Nervous System
Skin, Hair & Nails
Stress Management
Women's Health
Preferred pharmacy
Pharmacy name:       Location:
How did you get to know about MediClub?
I am introduced by my friend. My friend's name (as in IC or passport):
Website
Introduced by Medipharm's Product Advisor. Product Advisor's Name:
Introduced by pharmacy. Outlet's name:
Others. Please specify:
Please enter the key below to verify: