LAC-USC MEDICAL CENTER – HEALTHCARE NETWORK ATTENDING STAFF ASSOCIATION FOR THE DEPARTMENT OF DERMATOLOGY NAME OF APPLICANT DATE First order and/or additional privileges Renouncing applicant: Name: Page 1 First order Specialty Service All new applicants must meet the following requirements, as approved by the governing body with effect: Applicant: Check off the Requested 1 Poliklinik Cahah Branches 45, Jalan 34/154, Taman Delima Cheras Kuala Lumpur Tel: Fax: No 90, Solok Pendamar Indah 1, Taman Pendamar Indah, Port Klang Selangor Darul Ehsan Tel: Fax: No 79, Jalan Kampung Pandan, Kuala Lumpur Tel: Fax: Unit MFB-1, Mezzanine Floor, Sunway Tower, No.86, Jalan Ampang, Kuala Lumpur Tel Fax: No.1, Blok A, Jalan P8C/2,Presinct 8, Putrajaya Tel Fax: No.17, Jalan Pandan Perdana 4/5 , Pandan Perdana Kuala Lumpur Fax: No.74, Jalan Padang Belia, Off Jalan Tun Sambanthan 4, Kuala Lumpur Tel Fax: Dear Sir/Madam, APPLICATION FOR AS PANEL CLINIC Thank you for your interest in our health services. Here at the Cahaya Polyclinic Group of Clinics, we strive to offer the best health services to move excellence as a team. The Cahaya Polyclinic was founded in 1997 and we currently have seven clinics in the Sound Valley. With the increasing efficiency and trust of our customers, we are always expanding our practices and business to better serve our customers. Our clinics are run by a group of fully registered, qualified and dedicated doctors to our work. We provide medical and medical services at the primary care level and implement health and safety education programs for businesses in different sectors. It is an honour for us to be appointed to one of your panel clinics. More information on services and facilities is attached to this document. Please feel free to contact us for any further requests. Thank you very much.

Dr Pasupathi Nadarajan General Manager Polyclinic Cahaya Sdn Bhd A letter of appointment to the medical body should be formal. They contained z.B. all important information such as the clinic`s name, address and phone number. Medicina Clinic The best of medicine! 3 Ladies and gentlemen, JSC Medicina was founded more than 17 years ago and has been in service ever since. The purpose of the clinic is 2 Please note that this form can be completed online: POLYCLINIC CAHAYA (ALL BRANCHES) or POLYCLINIC CAHAYA, CHERAS POLIKLINIK CAHAYA, PANDAMARAN POLIKLINIK CAHAYA, KG PANDAN POLIKLINIK CAHAYA, SUNWAY TOWER POLIKLINIK CAHAYA, PUTRAJAYA POLIKLINIK CAHAYA, PANDAN PERDANA POLIKLINIK CAHAYA, BRICKFIELDS PANEL CLINIC FORM (Please check the box)