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The National Kidney Foundation - kidney screening
Consent for Release of Medical Information

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Schedule

PremiseDateTimeRegistration Deadline
Chaoyang School11 Nov 202411am to 2pm5 Nov 2024
Delta Senior School15 Nov 20241pm to 3pm11 Nov 2024
Tanglin School18 Nov 20241pm to 3pm12 Nov 2024
Katong School18 Nov 20242pm to 4pm12 Nov 2024
Centre for Adults28 Nov 20242pm to 4pm25 Nov 2024
Shared Services (APSN)
Shared Services (AESL)

Consent For Release of Medical Information

PART 1: PERSONAL PARTICULARS OF PATIENT

DD slash MM slash YYYY

Consent

I declare that the information given above is true and correct. I hereby give my consent for my medical information as per below and a copy of my screening laboratory report to be disclosed to The National Kidney Foundation for the purpose of data analysis on the incidence of Chronic Kidney Disease (CKD) according to risk factors. All disclosure(s) by The National Kidney Foundation, if any, will be made in accordance with PDPA 2012 and/or NKF’s Data Protection Notice.

DD slash MM slash YYYY

FOR OFFICIAL USE

PART 2: RISK FACTORS FOR CKD (Please tick accordingly)

Family history risk factors
Cardiometabolic risk factors
Renal risk factors
Other risk factors
Registration is now closed.
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