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PENTING/IMPORTANT
 Tempoh sah laku Borang Pemeriksaan Perubatan ini adalah 30 hari dari tarikh pendaftaran.
The validity of the Medical Examination Form is 30 days from the date of registration.
 Berkuatkuasa pada 01 Januari 2020, sebarang permohonan untuk pembatalan dan tuntutan bayaran balik pendaftaran pekerja
asing hanya dibenarkan dalam tempoh sah laku Borang Pemeriksaan Perubatan.
Effective on 01st January 2020, any request for cancellation and refund for foreign worker's registration only will be entertained
within validity period of the Medical Examination Form.
 Sila pastikan semua maklumat di atas adalah tepat.
Please ensure that all information stated above is correct.
 Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama passport asal untuk pemeriksaan perubatan.
Please bring along this Medical Examination Form together with the original passport for medical examination.
 FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain daripada
yang tersebut di atas.
FOMEMA will not responsible for any payment if the medical examination is carried out by medical facilities other than named above.

Prosedur Pemeriksaan Perubatan

(Untuk Perhatian Majikan)
1. Pekerja asing hanya dibenarkan membuat pemeriksaan perubatan dan X-Ray di Klinik/Pusat X-Ray seperti yang tercatat
dalam borang ini dalam masa 30 hari dari tarikh pendaftaran pekerja asing di FOMEMA.
2. Panel doktor dan pusat X-Ray FOMEMA TIDAK DIBENARKAN untuk menjalankan sebarang pemeriksaan perubatan
sekiranya pengesahan identiti dengan passport asal tidak dapat dilakukan.
3. Pekerja asing dikehendaki menjalani pemeriksaan fizikal oleh doktor terlebih dahulu sebelum menjalankan pemeriksaan
X-Ray.
4. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan fizikal dijalankan.
Majikan juga perlu menyimpan 'Salinan Majjikan' borang ini sebagai rujukan.
5. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 10 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui:

 Laman Web : www.fomema.com.my

 Menghubungi Pusat Perkhidmatan Pelanggan FOMEMA di talian 03-27828777
6. FOMEMA akan menghantar rekod keputusan pemeriksaan perubatan pekerja asing ke Ibu Pejabat Jabatan Imigresen, sehari
selepas mendapat pengesahan status perubatan pekerja asing daripada doktor yang memeriksa (kecuali kes-kes yang
memerlukan siasatan lanjut).

7. Status keputusan pemeriksaan perubatan pekerja asing dari FOMEMA hanya akan berada di Jabatan Imigresen selama 180
hari dari tarikh pemeriksaan perubatan dijalankan.

Medical Examination Procedure

(For Employer's Attention)
1. The foreign worker shall only be allowed to undertake the medical and X-Ray examination at the Clinic /X-Ray Facility printed
in this form within 30 days from the date of registration of foreign worker at FOMEMA.
2. FOMEMA's panel doctors and X-Ray Facilities is NOT ALLOWED to carry out any medical examination if the identity of the
foreign worker cannot be verified against the original passport.
3. The foreign worker must undergo the physical examination by the doctor before undergoing the X-Ray examination.
4. Please ensure that the date of the medical examination is duly filled by the doctor in this form after the physical examination.
The employer should retain the 'Employer's Copy' of this form as reference.
5. The status of medical examination result can be obtained within 10 working days from the date of the medical examination by
the doctor through:

 Website : www.fomema.com.my
 Contact FOMEMA's Customer Service Department : 03-27828777
6. FOMEMA only transmits the result of the foreign worker's medical examination to the Immigration Department of Malaysia on
the following day after the foreign worker has been certified by the doctor (except for the cases that require further
investigation).

7. The status of foreign worker's medical examination result from FOMEMA will only be available at the Immigration Department
of Malaysia for 180 days from the date the medical examination was carried out.
 BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :
Examination Date
Medical Examination Form
Tandatangan Doctor :
Doctor's Signature
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Cop Klinik :
ALLOWED FOR CANCELLATION/ REFUND Clinic's Stamp

BEFORE 06/10/2020
Kod Perkerja: W9ER210929
Worker's Code
Name Pekerja : RAJA RAMILA No. Pasport : N8473607
Worker's Name Passport No.
Jantina : FEMALE Negara Asal : SRI LANKA
Gender Country of Origin
Tarikh Lahir : 14-01-1996 Tarikh Pendaftaran : 07-09-2020
Date of Birth Date of Registration
Telefon Majikan : 0162335464 Majikan : SHAMILAR A/P SIVARAJA SINGHAM
Employer Contact No. Employer
No. Telefon Doktor : 0377822368 No. Telefon X-Ray : 0379816800
Doctor Telephone No. X-Ray Telephone No.
Sah Sehingga : 06/10/2020 Kod Majikan : E2ES043872
Valid Until Employer's Code :

Tarikh Pemeriksaan :
Examination Date
Kod Doctor : D5BB000003 Kod Pekerja : W9ER210929 Jantina : FEMALE
Doctor's Code Worker's Code Gender
Nama Doktor : BHAMINI A/P S RAJA CHANDRAN No. Pasport : N8473607
Doctor's Name Passport No.
Nama Klinik KLINIK BAMZ HEALTHCARE Nama Pekerja : RAJA RAMILA
& Alamat : NO 12 GROUND FLOOR JLN SRI JATI 1, TMN SRI Worker's Name
Clinic's Name JATIOFF JLN PUCHONG 58200 PUCHONG KUALA Sah Sehingga : 06/10/2020
& Address Valid Until
LUMPUR

No. Telefon : 0377822368 No. Telefon Majikan :0162335464 Tandatangan Doktor : Cop Klinik :
Telephone No. Employer Contact No. Doctor's Signature Clinic's Stamp

Nama Pekerja : RAJA RAMILA

Worker's Name :RAJA RAMILA

Worker's Code : W9ER210929
Trans ID : 20200907573566
Worker's Name
Kod Doctor : D5BB000003 No. Pasport : N8473607
Doctor's Code Passport No.
Kod Makmal : L64P000005 Kod Pekerja : W9ER210929 Jantina :
FEMALE
Laboratory's Code Worker's Code Gender
Nama Makmal PANTAI PREMIER PATHOLOGY Nama Klinik KLINIK BAMZ HEALTHCARE
& Alamat : SDN BHD & Alamat : NO 12 GROUND FLOOR JLN SRI
Laboratory's Name Clinic Name
& Address LG FLOOR, MOB BLOCK PANTAI & Address JATI 1, TMN SRI JATIOFF JLN
HOSPITAL AMPANGJALAN PUCHONG 58200 PUCHONG
PERUBATAN 3PANDAN INDAH KUALA LUMPUR
55100 CHERAS KUALA LUMPUR

No. Telefon : 0342809115 Sah Sehingga : 06/10/2020 No. Telefon Majikan :0162335464
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan : Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp

Nama Pekerja : RAJA RAMILA

Worker's Name :RAJA RAMILA
Worker's Code : W9ER210929
Trans ID : 20200907573566

Worker's Name
Kod X-Ray: X34P000026 Kod Pekerja : W9ER210929 Jantina: FEMALE
X-Ray's Code Worker's Code Gender
No. Pasport: N8473607
Passport No.
Nama Fasiliti POLIKLINIK UNITED Nama Klinik KLINIK BAMZ HEALTHCARE
X-Ray & Alamat :BLOCK A, LOT 107 NO.11, JALAN & Alamat : NO 12 GROUND FLOOR JLN SRI
X-Ray's Facility SEPADUUNITED GARDEN 58200 Clinic Name JATI 1, TMN SRI JATIOFF JLN
Name & Address & Address
JLN KLANG LAMA KUALA LUMPUR PUCHONG 58200 PUCHONG
KUALA LUMPUR

No. Telefon : 0379816800 Sah Sehingga : 06/10/2020 No. Telefon Majikan :0162335464
Telephone No. Valid Until Employer Contact No.
Tarikh Pemeriksaan : Tandatangan Doktor : Cop Klinik :
Examination Date Doctor's Signature Clinic's Stamp