First Name *

Last Name *


IC / Passport Number *

Marital Status *

Date of Birth *

Mobile Phone Number *

Home Telephone *

Desired Screening Date (We are closed on Thurs, Sun & Public Holidays)

Desired Screening Time
(7.40, 8.10, 8.40, 9.10 or 9.40)am

Address *

City *

State *

Postal Code *

Country *

AntiSpam Challenge:6+3 = ? *

Terms & Conditions:

* This is an application form for MJLife Health Screening membership.

* All members can enjoy subsequent full Health screening at a low rate of RM780

* All members will be issued an MJLife member card.

* Membership is lifetime. There are no yearly renewal or maintenance fees.

* All information will be kept private. We will not share your information with any third parties.

* For more than 1 pax or family package, please call our hotline at 017-3082078 and enquire for pricing.

* Investment for health management membership: RM2988 per pax (lifetime).

* Other terms and conditions apply.