Date:
To: Eurofins Clinical Diagnostics Pte Ltd (“Eurofins”) 1 International Business Park #03-17, The Synergy, Singapore 609917 Tel: +65 6797-8899 Fax: +65 6797-8897
From: Requesting Clinic (“The Clinic”)
Clinic Name:
HCI Code:
Doctor in-charge:
Doctor MCR No.:
We hereby authorise Eurofins Clinical Diagnostics Pte Ltd to electronically transmit our Patients Results including demographic data, test order and test results to the Electronic Platform / Clinic Management System provided by vendor with effect from .
We agree and acknowledge that:
1. The Clinic shall obtain the consent of patients to conform with the Personal Data Protection Act 2012 (PDPA) for the transmission of Patients Results to the Vendor’s system;
2. In transmitting Patients Results to our appointed Vendor, Eurofins is acting in accordance with The Clinic’s instructions. The Patients Results are being transmitted to the Vendor at the request of The Clinic and at The Clinic’s own risk;
3. The Clinic shall ensure the compliance of the Vendor with all applicable obligations of the provisions of the PDPA;
4. The Clinic shall not hold Eurofins liable for any loss or damage which may be suffered by The Clinic in connection with the electronic transmission of Patients Results via the Vendor’s Electronic Platform / Clinic Management System.
Name:
Clinic Stamp
Clinic Address:
