Prosedur Pemeriksaan Perubatan

(Untuk Perhatian Majikan)

1. Sila pastikan semua maklumat di Borang Pemeriksaan Perubatan ini adalah tepat.
2. Tempoh sah laku Borang Pemeriksaan Perubatan adalah 30 hari dari tarikh pendaftaran.
3. Majikan perlu melengkapkan pemeriksaan kesihatan dalam tempoh tujuh (7) hari bekerja dari tarikh mereka tiba di klinik.
4. Sebarang permohonan pembatalan pendaftaran dan tuntutan bayaran balik hanya dibenarkan dalam tempoh sah laku
Borang Pemeriksaan Perubatan; tertakluk kepada yuran perkhidmatan sebanyak RM27.00 bagi setiap pekerja asing.
5. Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama pasport asal untuk pemeriksaan perubatan dan X-ray.
Pihak FOMEMA hanya membenarkan panel doktor dan pusat X-ray untuk menjalankan pemeriksaan perubatan dan X-ray
sekiranya pengesahan identiti Pekerja Asing dilakukan dengan pasport asal.
6. FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain
daripada yang tercatat dalam borang ini.
7. Pekerja asing dikehendaki menjalani pemeriksaan perubatan oleh doktor terlebih dahulu sebelum menjalankan
pemeriksaan X-ray.
8. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan perubatan
dijalankan.
9. Majikan juga perlu menyimpan keratan "Salinan Majikan" sebagai rujukan.
10. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 7 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui Portal FOMEMA: https://portal.fomema.my
11. Rekod keputusan pemeriksaan perubatan pekerja asing akan dihantar ke Jabatan Imigresen Malaysia setelah proses
perubatan selesai.
12. Status keputusan pemeriksaan perubatan pekerja asing FOMEMA di Jabatan Imigresen Malaysia hanya sah selama 180
hari dari tarikh pemeriksaan perubatan dijalankan.

Medical Examination Procedure

(For Employer's Attention)
1. Please ensure that all information on this Medical Examination Form is accurate.
2. The validity period of the Medical Examination Form is 30 days from the date of registration.
3. Employer must complete medical examination within seven (7) working days from the date of their arrival at the clinic.
4. Any request for cancellation of registration and refund request is only allowed within the validity period of the Medical
Examination Form; will be subjected to a service fee of RM27.00 for each worker.
5. Please ensure that this Medical Examination Form is brought together with the original passport of the foreign worker for
medical examination. FOMEMA only allows registered panel doctors and X-ray centers to conduct medical examinations
and X-ray after verification of the identity of the foreign worker is done with the original passport.
6. FOMEMA will not be responsible for any payment if the medical examination is carried out by medical facilities other than
named below.
7. The foreign worker must undergo the physical examination by the doctor before undergoing the X-ray examination
8. Please ensure that the date of the medical examination is duly filled by the doctor in this form after the physical examination
has been completed.
9. The employers should retain the "Employer's Copy" of this form as reference
10. The status of medical examination result can be obtained within 7 working days from the date of the medical examination
by the doctor through FOMEMA Online Portal: https://portal.fomema.my
11. The result of the foreign worker's medical examination will be transmitted to the Immigration Department of Malaysia once
completed
12. The status of FOMEMA foreign worker medical examination results at the Immigration Department of Malaysia is only valid
for 180 days from the date of medical examination was carried out.

Document : FM-MEF-OPS Page: 1/2

Revision / Date : 02/06-23
 BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :
Examination Date
MEDICAL EXAMINATION FORM
Tandatangan Doktor :
Doctor's Signature

Sah Sehingga/ Valid Until: 14/01/2025 Cop Klinik :

Cancellation/ Refund before 14/01/2025 Clinic's Stamp

Kod Pekerja: W9AZ020287

Worker Code
Nama Pekerja: ZADA ASHIQ Tarikh Pendaftaran: 16-12-2024
Worker Name Date of Registration
3 NEW TESTS
No. Pasport: AD5497064 Nama Majikan: AMALAN UTAMA TRADING
Passport No. Employer Name
Negara: PAKISTAN Kod Majikan: E51A010388
Country Employer Code
Jantina: MALE No. Telefon Doktor: 043334652
Gender Doctor Telephone No.
Tarikh Lahir: 01-01-1978 No. Telefon X-Ray: 043328146
Date of Birth X-Ray Telephone No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Doktor: D2AS000047 ID Trans: 20241216631718
Doctor's Code Trans ID
Nama Doktor: SALEK MUNHAR BIN ABD LATIF Kod Pekerja: W9AZ020287
Doctor Name Worker Code
Nama Klinik & KLINIK RAWATAN DR MAHMUD Nama Pekerja: ZADA ASHIQ
Alamat: 4452, JALAN BAGAN LUAR Worker Name
Clinic Name & 12000 BUTTERWORTH PULAU PINANG
No. Pasport: AD5497064
Address Passport No.
Jantina: MALE
Gender
Tandatangan Doktor :
Doctor's Signature
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan : 043902011
Clinic's Stamp Examination Date Employer Contact No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Makmal: L8AI000001 Kod Doktor: D2AS000047
Laboratory's Code Doctor's Code
No Telefon: 045489614 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631718
Nama Makmal & INTEGRATED REFERENCE Nama Klinik & KLINIK RAWATAN DR Trans ID
Alamat: LABORATORIES SDN BHD Alamat: MAHMUD Kod Perkerja: W9AZ020287
Laboratory's NO. 17, 1ST FLOOR Clinic Name & 4452, JALAN BAGAN LUAR Worker's Code
Name & Address LORONG PERDA UTAMA 9 Address 12000 BUTTERWORTH PULAU
Nama Pekerja: ZADA ASHIQ
BANDAR PERDA PINANG
14000 BUKIT MERTAJAM Worker's Name
PULAU PINANG
No. Passport: AD5497064
Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan:
Clinic's Stamp Examination Date

Sah Sehingga/ Valid Until: 14/01/2025

Kod X-Ray: X7AL000003 Kod Doktor: D2AS000047

X-Ray's Code Doctor's Code
No. Telefon: 043328146 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631718
Nama Fasiliti LING KLINIK Nama Klinik KLINIK RAWATAN DR Trans ID
X-Ray & Alamat: 4220, JALAN KAMPONG & Alamat: MAHMUD Kod Pekerja: W9AZ020287
X-Ray's Facility BENGALI Clinic Name 4452, JALAN BAGAN LUAR Worker's Code
Name & 12200 BUTTERWORTH PULAU & Address 12000 BUTTERWORTH PULAU
PINANG PINANG Nama Pekerja: ZADA ASHIQ
Address Worker's Name

No. Pasport AD5497064

Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan: 043902011
Clinic's Stamp Examination Date Employer Contact No.
Page: 2/2
 Prosedur Pemeriksaan Perubatan
(Untuk Perhatian Majikan)
1. Sila pastikan semua maklumat di Borang Pemeriksaan Perubatan ini adalah tepat.
2. Tempoh sah laku Borang Pemeriksaan Perubatan adalah 30 hari dari tarikh pendaftaran.
3. Majikan perlu melengkapkan pemeriksaan kesihatan dalam tempoh tujuh (7) hari bekerja dari tarikh mereka tiba di klinik.
4. Sebarang permohonan pembatalan pendaftaran dan tuntutan bayaran balik hanya dibenarkan dalam tempoh sah laku
Borang Pemeriksaan Perubatan; tertakluk kepada yuran perkhidmatan sebanyak RM27.00 bagi setiap pekerja asing.
5. Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama pasport asal untuk pemeriksaan perubatan dan X-ray.
Pihak FOMEMA hanya membenarkan panel doktor dan pusat X-ray untuk menjalankan pemeriksaan perubatan dan X-ray
sekiranya pengesahan identiti Pekerja Asing dilakukan dengan pasport asal.
6. FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain
daripada yang tercatat dalam borang ini.
7. Pekerja asing dikehendaki menjalani pemeriksaan perubatan oleh doktor terlebih dahulu sebelum menjalankan
pemeriksaan X-ray.
8. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan perubatan
dijalankan.
9. Majikan juga perlu menyimpan keratan "Salinan Majikan" sebagai rujukan.
10. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 7 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui Portal FOMEMA: https://portal.fomema.my
11. Rekod keputusan pemeriksaan perubatan pekerja asing akan dihantar ke Jabatan Imigresen Malaysia setelah proses
perubatan selesai.
12. Status keputusan pemeriksaan perubatan pekerja asing FOMEMA di Jabatan Imigresen Malaysia hanya sah selama 180
hari dari tarikh pemeriksaan perubatan dijalankan.

Medical Examination Procedure

(For Employer's Attention)
1. Please ensure that all information on this Medical Examination Form is accurate.
2. The validity period of the Medical Examination Form is 30 days from the date of registration.
3. Employer must complete medical examination within seven (7) working days from the date of their arrival at the clinic.
4. Any request for cancellation of registration and refund request is only allowed within the validity period of the Medical
Examination Form; will be subjected to a service fee of RM27.00 for each worker.
5. Please ensure that this Medical Examination Form is brought together with the original passport of the foreign worker for
medical examination. FOMEMA only allows registered panel doctors and X-ray centers to conduct medical examinations
and X-ray after verification of the identity of the foreign worker is done with the original passport.
6. FOMEMA will not be responsible for any payment if the medical examination is carried out by medical facilities other than
named below.
7. The foreign worker must undergo the physical examination by the doctor before undergoing the X-ray examination
8. Please ensure that the date of the medical examination is duly filled by the doctor in this form after the physical examination
has been completed.
9. The employers should retain the "Employer's Copy" of this form as reference
10. The status of medical examination result can be obtained within 7 working days from the date of the medical examination
by the doctor through FOMEMA Online Portal: https://portal.fomema.my
11. The result of the foreign worker's medical examination will be transmitted to the Immigration Department of Malaysia once
completed
12. The status of FOMEMA foreign worker medical examination results at the Immigration Department of Malaysia is only valid
for 180 days from the date of medical examination was carried out.

Document : FM-MEF-OPS Page: 1/2

Revision / Date : 02/06-23
 BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :
Examination Date
MEDICAL EXAMINATION FORM
Tandatangan Doktor :
Doctor's Signature

Sah Sehingga/ Valid Until: 14/01/2025 Cop Klinik :

Cancellation/ Refund before 14/01/2025 Clinic's Stamp

Kod Pekerja: W3AS144722

Worker Code
Nama Pekerja: SHAH MUHAMMAD Tarikh Pendaftaran: 16-12-2024
Worker Name Date of Registration
3 NEW TESTS
No. Pasport: LK5169731 Nama Majikan: AMALAN UTAMA TRADING
Passport No. Employer Name
Negara: PAKISTAN Kod Majikan: E51A010388
Country Employer Code
Jantina: MALE No. Telefon Doktor: 043334652
Gender Doctor Telephone No.
Tarikh Lahir: 20-05-2005 No. Telefon X-Ray: 043328146
Date of Birth X-Ray Telephone No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Doktor: D2AS000047 ID Trans: 20241216631717
Doctor's Code Trans ID
Nama Doktor: SALEK MUNHAR BIN ABD LATIF Kod Pekerja: W3AS144722
Doctor Name Worker Code
Nama Klinik & KLINIK RAWATAN DR MAHMUD Nama Pekerja: SHAH MUHAMMAD
Alamat: 4452, JALAN BAGAN LUAR Worker Name
Clinic Name & 12000 BUTTERWORTH PULAU PINANG
No. Pasport: LK5169731
Address Passport No.
Jantina: MALE
Gender
Tandatangan Doktor :
Doctor's Signature
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan : 043902011
Clinic's Stamp Examination Date Employer Contact No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Makmal: L8AI000001 Kod Doktor: D2AS000047
Laboratory's Code Doctor's Code
No Telefon: 045489614 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631717
Nama Makmal & INTEGRATED REFERENCE Nama Klinik & KLINIK RAWATAN DR Trans ID
Alamat: LABORATORIES SDN BHD Alamat: MAHMUD Kod Perkerja: W3AS144722
Laboratory's NO. 17, 1ST FLOOR Clinic Name & 4452, JALAN BAGAN LUAR Worker's Code
Name & Address LORONG PERDA UTAMA 9 Address 12000 BUTTERWORTH PULAU
Nama Pekerja: SHAH MUHAMMAD
BANDAR PERDA PINANG
14000 BUKIT MERTAJAM Worker's Name
PULAU PINANG
No. Passport: LK5169731
Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan:
Clinic's Stamp Examination Date

Sah Sehingga/ Valid Until: 14/01/2025

Kod X-Ray: X7AL000003 Kod Doktor: D2AS000047

X-Ray's Code Doctor's Code
No. Telefon: 043328146 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631717
Nama Fasiliti LING KLINIK Nama Klinik KLINIK RAWATAN DR Trans ID
X-Ray & Alamat: 4220, JALAN KAMPONG & Alamat: MAHMUD Kod Pekerja: W3AS144722
X-Ray's Facility BENGALI Clinic Name 4452, JALAN BAGAN LUAR Worker's Code
Name & 12200 BUTTERWORTH PULAU & Address 12000 BUTTERWORTH PULAU
PINANG PINANG Nama Pekerja: SHAH MUHAMMAD
Address Worker's Name

No. Pasport LK5169731

Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan: 043902011
Clinic's Stamp Examination Date Employer Contact No.
Page: 2/2
 Prosedur Pemeriksaan Perubatan
(Untuk Perhatian Majikan)
1. Sila pastikan semua maklumat di Borang Pemeriksaan Perubatan ini adalah tepat.
2. Tempoh sah laku Borang Pemeriksaan Perubatan adalah 30 hari dari tarikh pendaftaran.
3. Majikan perlu melengkapkan pemeriksaan kesihatan dalam tempoh tujuh (7) hari bekerja dari tarikh mereka tiba di klinik.
4. Sebarang permohonan pembatalan pendaftaran dan tuntutan bayaran balik hanya dibenarkan dalam tempoh sah laku
Borang Pemeriksaan Perubatan; tertakluk kepada yuran perkhidmatan sebanyak RM27.00 bagi setiap pekerja asing.
5. Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama pasport asal untuk pemeriksaan perubatan dan X-ray.
Pihak FOMEMA hanya membenarkan panel doktor dan pusat X-ray untuk menjalankan pemeriksaan perubatan dan X-ray
sekiranya pengesahan identiti Pekerja Asing dilakukan dengan pasport asal.
6. FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain
daripada yang tercatat dalam borang ini.
7. Pekerja asing dikehendaki menjalani pemeriksaan perubatan oleh doktor terlebih dahulu sebelum menjalankan
pemeriksaan X-ray.
8. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan perubatan
dijalankan.
9. Majikan juga perlu menyimpan keratan "Salinan Majikan" sebagai rujukan.
10. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 7 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui Portal FOMEMA: https://portal.fomema.my
11. Rekod keputusan pemeriksaan perubatan pekerja asing akan dihantar ke Jabatan Imigresen Malaysia setelah proses
perubatan selesai.
12. Status keputusan pemeriksaan perubatan pekerja asing FOMEMA di Jabatan Imigresen Malaysia hanya sah selama 180
hari dari tarikh pemeriksaan perubatan dijalankan.

Medical Examination Procedure

(For Employer's Attention)
1. Please ensure that all information on this Medical Examination Form is accurate.
2. The validity period of the Medical Examination Form is 30 days from the date of registration.
3. Employer must complete medical examination within seven (7) working days from the date of their arrival at the clinic.
4. Any request for cancellation of registration and refund request is only allowed within the validity period of the Medical
Examination Form; will be subjected to a service fee of RM27.00 for each worker.
5. Please ensure that this Medical Examination Form is brought together with the original passport of the foreign worker for
medical examination. FOMEMA only allows registered panel doctors and X-ray centers to conduct medical examinations
and X-ray after verification of the identity of the foreign worker is done with the original passport.
6. FOMEMA will not be responsible for any payment if the medical examination is carried out by medical facilities other than
named below.
7. The foreign worker must undergo the physical examination by the doctor before undergoing the X-ray examination
8. Please ensure that the date of the medical examination is duly filled by the doctor in this form after the physical examination
has been completed.
9. The employers should retain the "Employer's Copy" of this form as reference
10. The status of medical examination result can be obtained within 7 working days from the date of the medical examination
by the doctor through FOMEMA Online Portal: https://portal.fomema.my
11. The result of the foreign worker's medical examination will be transmitted to the Immigration Department of Malaysia once
completed
12. The status of FOMEMA foreign worker medical examination results at the Immigration Department of Malaysia is only valid
for 180 days from the date of medical examination was carried out.

Document : FM-MEF-OPS Page: 1/2

Revision / Date : 02/06-23
 BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :
Examination Date
MEDICAL EXAMINATION FORM
Tandatangan Doktor :
Doctor's Signature

Sah Sehingga/ Valid Until: 14/01/2025 Cop Klinik :

Cancellation/ Refund before 14/01/2025 Clinic's Stamp

Kod Pekerja: W6AR071205

Worker Code
Nama Pekerja: RAHMAN ZIA UR Tarikh Pendaftaran: 16-12-2024
Worker Name Date of Registration
3 NEW TESTS
No. Pasport: XK9158971 Nama Majikan: AMALAN UTAMA TRADING
Passport No. Employer Name
Negara: PAKISTAN Kod Majikan: E51A010388
Country Employer Code
Jantina: MALE No. Telefon Doktor: 043334652
Gender Doctor Telephone No.
Tarikh Lahir: 05-04-1993 No. Telefon X-Ray: 043328146
Date of Birth X-Ray Telephone No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Doktor: D2AS000047 ID Trans: 20241216631716
Doctor's Code Trans ID
Nama Doktor: SALEK MUNHAR BIN ABD LATIF Kod Pekerja: W6AR071205
Doctor Name Worker Code
Nama Klinik & KLINIK RAWATAN DR MAHMUD Nama Pekerja: RAHMAN ZIA UR
Alamat: 4452, JALAN BAGAN LUAR Worker Name
Clinic Name & 12000 BUTTERWORTH PULAU PINANG
No. Pasport: XK9158971
Address Passport No.
Jantina: MALE
Gender
Tandatangan Doktor :
Doctor's Signature
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan : 043902011
Clinic's Stamp Examination Date Employer Contact No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Makmal: L8AI000001 Kod Doktor: D2AS000047
Laboratory's Code Doctor's Code
No Telefon: 045489614 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631716
Nama Makmal & INTEGRATED REFERENCE Nama Klinik & KLINIK RAWATAN DR Trans ID
Alamat: LABORATORIES SDN BHD Alamat: MAHMUD Kod Perkerja: W6AR071205
Laboratory's NO. 17, 1ST FLOOR Clinic Name & 4452, JALAN BAGAN LUAR Worker's Code
Name & Address LORONG PERDA UTAMA 9 Address 12000 BUTTERWORTH PULAU
Nama Pekerja: RAHMAN ZIA UR
BANDAR PERDA PINANG
14000 BUKIT MERTAJAM Worker's Name
PULAU PINANG
No. Passport: XK9158971
Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan:
Clinic's Stamp Examination Date

Sah Sehingga/ Valid Until: 14/01/2025

Kod X-Ray: X7AL000003 Kod Doktor: D2AS000047

X-Ray's Code Doctor's Code
No. Telefon: 043328146 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631716
Nama Fasiliti LING KLINIK Nama Klinik KLINIK RAWATAN DR Trans ID
X-Ray & Alamat: 4220, JALAN KAMPONG & Alamat: MAHMUD Kod Pekerja: W6AR071205
X-Ray's Facility BENGALI Clinic Name 4452, JALAN BAGAN LUAR Worker's Code
Name & 12200 BUTTERWORTH PULAU & Address 12000 BUTTERWORTH PULAU
PINANG PINANG Nama Pekerja: RAHMAN ZIA UR
Address Worker's Name

No. Pasport XK9158971

Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan: 043902011
Clinic's Stamp Examination Date Employer Contact No.
Page: 2/2
 Prosedur Pemeriksaan Perubatan
(Untuk Perhatian Majikan)
1. Sila pastikan semua maklumat di Borang Pemeriksaan Perubatan ini adalah tepat.
2. Tempoh sah laku Borang Pemeriksaan Perubatan adalah 30 hari dari tarikh pendaftaran.
3. Majikan perlu melengkapkan pemeriksaan kesihatan dalam tempoh tujuh (7) hari bekerja dari tarikh mereka tiba di klinik.
4. Sebarang permohonan pembatalan pendaftaran dan tuntutan bayaran balik hanya dibenarkan dalam tempoh sah laku
Borang Pemeriksaan Perubatan; tertakluk kepada yuran perkhidmatan sebanyak RM27.00 bagi setiap pekerja asing.
5. Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama pasport asal untuk pemeriksaan perubatan dan X-ray.
Pihak FOMEMA hanya membenarkan panel doktor dan pusat X-ray untuk menjalankan pemeriksaan perubatan dan X-ray
sekiranya pengesahan identiti Pekerja Asing dilakukan dengan pasport asal.
6. FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain
daripada yang tercatat dalam borang ini.
7. Pekerja asing dikehendaki menjalani pemeriksaan perubatan oleh doktor terlebih dahulu sebelum menjalankan
pemeriksaan X-ray.
8. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan perubatan
dijalankan.
9. Majikan juga perlu menyimpan keratan "Salinan Majikan" sebagai rujukan.
10. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 7 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui Portal FOMEMA: https://portal.fomema.my
11. Rekod keputusan pemeriksaan perubatan pekerja asing akan dihantar ke Jabatan Imigresen Malaysia setelah proses
perubatan selesai.
12. Status keputusan pemeriksaan perubatan pekerja asing FOMEMA di Jabatan Imigresen Malaysia hanya sah selama 180
hari dari tarikh pemeriksaan perubatan dijalankan.

Medical Examination Procedure

(For Employer's Attention)
1. Please ensure that all information on this Medical Examination Form is accurate.
2. The validity period of the Medical Examination Form is 30 days from the date of registration.
3. Employer must complete medical examination within seven (7) working days from the date of their arrival at the clinic.
4. Any request for cancellation of registration and refund request is only allowed within the validity period of the Medical
Examination Form; will be subjected to a service fee of RM27.00 for each worker.
5. Please ensure that this Medical Examination Form is brought together with the original passport of the foreign worker for
medical examination. FOMEMA only allows registered panel doctors and X-ray centers to conduct medical examinations
and X-ray after verification of the identity of the foreign worker is done with the original passport.
6. FOMEMA will not be responsible for any payment if the medical examination is carried out by medical facilities other than
named below.
7. The foreign worker must undergo the physical examination by the doctor before undergoing the X-ray examination
8. Please ensure that the date of the medical examination is duly filled by the doctor in this form after the physical examination
has been completed.
9. The employers should retain the "Employer's Copy" of this form as reference
10. The status of medical examination result can be obtained within 7 working days from the date of the medical examination
by the doctor through FOMEMA Online Portal: https://portal.fomema.my
11. The result of the foreign worker's medical examination will be transmitted to the Immigration Department of Malaysia once
completed
12. The status of FOMEMA foreign worker medical examination results at the Immigration Department of Malaysia is only valid
for 180 days from the date of medical examination was carried out.

Document : FM-MEF-OPS Page: 1/2

Revision / Date : 02/06-23
 BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :
Examination Date
MEDICAL EXAMINATION FORM
Tandatangan Doktor :
Doctor's Signature

Sah Sehingga/ Valid Until: 14/01/2025 Cop Klinik :

Cancellation/ Refund before 14/01/2025 Clinic's Stamp

Kod Pekerja: W5AB039333

Worker Code
Nama Pekerja: BACHA UMAR Tarikh Pendaftaran: 16-12-2024
Worker Name Date of Registration
3 NEW TESTS
No. Pasport: BB3344004 Nama Majikan: AMALAN UTAMA TRADING
Passport No. Employer Name
Negara: PAKISTAN Kod Majikan: E51A010388
Country Employer Code
Jantina: MALE No. Telefon Doktor: 043334652
Gender Doctor Telephone No.
Tarikh Lahir: 09-03-1990 No. Telefon X-Ray: 043328146
Date of Birth X-Ray Telephone No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Doktor: D2AS000047 ID Trans: 20241216631715
Doctor's Code Trans ID
Nama Doktor: SALEK MUNHAR BIN ABD LATIF Kod Pekerja: W5AB039333
Doctor Name Worker Code
Nama Klinik & KLINIK RAWATAN DR MAHMUD Nama Pekerja: BACHA UMAR
Alamat: 4452, JALAN BAGAN LUAR Worker Name
Clinic Name & 12000 BUTTERWORTH PULAU PINANG
No. Pasport: BB3344004
Address Passport No.
Jantina: MALE
Gender
Tandatangan Doktor :
Doctor's Signature
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan : 043902011
Clinic's Stamp Examination Date Employer Contact No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Makmal: L8AI000001 Kod Doktor: D2AS000047
Laboratory's Code Doctor's Code
No Telefon: 045489614 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631715
Nama Makmal & INTEGRATED REFERENCE Nama Klinik & KLINIK RAWATAN DR Trans ID
Alamat: LABORATORIES SDN BHD Alamat: MAHMUD Kod Perkerja: W5AB039333
Laboratory's NO. 17, 1ST FLOOR Clinic Name & 4452, JALAN BAGAN LUAR Worker's Code
Name & Address LORONG PERDA UTAMA 9 Address 12000 BUTTERWORTH PULAU
Nama Pekerja: BACHA UMAR
BANDAR PERDA PINANG
14000 BUKIT MERTAJAM Worker's Name
PULAU PINANG
No. Passport: BB3344004
Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan:
Clinic's Stamp Examination Date

Sah Sehingga/ Valid Until: 14/01/2025

Kod X-Ray: X7AL000003 Kod Doktor: D2AS000047

X-Ray's Code Doctor's Code
No. Telefon: 043328146 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631715
Nama Fasiliti LING KLINIK Nama Klinik KLINIK RAWATAN DR Trans ID
X-Ray & Alamat: 4220, JALAN KAMPONG & Alamat: MAHMUD Kod Pekerja: W5AB039333
X-Ray's Facility BENGALI Clinic Name 4452, JALAN BAGAN LUAR Worker's Code
Name & 12200 BUTTERWORTH PULAU & Address 12000 BUTTERWORTH PULAU
PINANG PINANG Nama Pekerja: BACHA UMAR
Address Worker's Name

No. Pasport BB3344004

Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan: 043902011
Clinic's Stamp Examination Date Employer Contact No.
Page: 2/2
 Prosedur Pemeriksaan Perubatan
(Untuk Perhatian Majikan)
1. Sila pastikan semua maklumat di Borang Pemeriksaan Perubatan ini adalah tepat.
2. Tempoh sah laku Borang Pemeriksaan Perubatan adalah 30 hari dari tarikh pendaftaran.
3. Majikan perlu melengkapkan pemeriksaan kesihatan dalam tempoh tujuh (7) hari bekerja dari tarikh mereka tiba di klinik.
4. Sebarang permohonan pembatalan pendaftaran dan tuntutan bayaran balik hanya dibenarkan dalam tempoh sah laku
Borang Pemeriksaan Perubatan; tertakluk kepada yuran perkhidmatan sebanyak RM27.00 bagi setiap pekerja asing.
5. Sila pastikan Borang Pemeriksaan Perubatan ini dibawa bersama pasport asal untuk pemeriksaan perubatan dan X-ray.
Pihak FOMEMA hanya membenarkan panel doktor dan pusat X-ray untuk menjalankan pemeriksaan perubatan dan X-ray
sekiranya pengesahan identiti Pekerja Asing dilakukan dengan pasport asal.
6. FOMEMA tidak bertanggungjawab ke atas pembayaran sekiranya pemeriksaan perubatan dijalankan oleh klinik selain
daripada yang tercatat dalam borang ini.
7. Pekerja asing dikehendaki menjalani pemeriksaan perubatan oleh doktor terlebih dahulu sebelum menjalankan
pemeriksaan X-ray.
8. Sila pastikan tarikh pemeriksaan doktor telah diisi oleh doktor di dalam borang ini selepas pemeriksaan perubatan
dijalankan.
9. Majikan juga perlu menyimpan keratan "Salinan Majikan" sebagai rujukan.
10. Status keputusan pemeriksaan perubatan pekerja boleh disemak dalam masa 7 hari bekerja dari tarikh pemeriksaan
perubatan dijalankan oleh doktor melalui Portal FOMEMA: https://portal.fomema.my
11. Rekod keputusan pemeriksaan perubatan pekerja asing akan dihantar ke Jabatan Imigresen Malaysia setelah proses
perubatan selesai.
12. Status keputusan pemeriksaan perubatan pekerja asing FOMEMA di Jabatan Imigresen Malaysia hanya sah selama 180
hari dari tarikh pemeriksaan perubatan dijalankan.

Medical Examination Procedure

(For Employer's Attention)
1. Please ensure that all information on this Medical Examination Form is accurate.
2. The validity period of the Medical Examination Form is 30 days from the date of registration.
3. Employer must complete medical examination within seven (7) working days from the date of their arrival at the clinic.
4. Any request for cancellation of registration and refund request is only allowed within the validity period of the Medical
Examination Form; will be subjected to a service fee of RM27.00 for each worker.
5. Please ensure that this Medical Examination Form is brought together with the original passport of the foreign worker for
medical examination. FOMEMA only allows registered panel doctors and X-ray centers to conduct medical examinations
and X-ray after verification of the identity of the foreign worker is done with the original passport.
6. FOMEMA will not be responsible for any payment if the medical examination is carried out by medical facilities other than
named below.
7. The foreign worker must undergo the physical examination by the doctor before undergoing the X-ray examination
8. Please ensure that the date of the medical examination is duly filled by the doctor in this form after the physical examination
has been completed.
9. The employers should retain the "Employer's Copy" of this form as reference
10. The status of medical examination result can be obtained within 7 working days from the date of the medical examination
by the doctor through FOMEMA Online Portal: https://portal.fomema.my
11. The result of the foreign worker's medical examination will be transmitted to the Immigration Department of Malaysia once
completed
12. The status of FOMEMA foreign worker medical examination results at the Immigration Department of Malaysia is only valid
for 180 days from the date of medical examination was carried out.

Document : FM-MEF-OPS Page: 1/2

Revision / Date : 02/06-23
 BORANG PEMERIKSAAN PERUBATAN Tarikh Pemeriksaan :
Examination Date
MEDICAL EXAMINATION FORM
Tandatangan Doktor :
Doctor's Signature

Sah Sehingga/ Valid Until: 14/01/2025 Cop Klinik :

Cancellation/ Refund before 14/01/2025 Clinic's Stamp

Kod Pekerja: W6AA082481

Worker Code
Nama Pekerja: ALI NADEEM Tarikh Pendaftaran: 16-12-2024
Worker Name Date of Registration
3 NEW TESTS
No. Pasport: ST1831641 Nama Majikan: AMALAN UTAMA TRADING
Passport No. Employer Name
Negara: PAKISTAN Kod Majikan: E51A010388
Country Employer Code
Jantina: MALE No. Telefon Doktor: 043334652
Gender Doctor Telephone No.
Tarikh Lahir: 02-08-2003 No. Telefon X-Ray: 043328146
Date of Birth X-Ray Telephone No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Doktor: D2AS000047 ID Trans: 20241216631714
Doctor's Code Trans ID
Nama Doktor: SALEK MUNHAR BIN ABD LATIF Kod Pekerja: W6AA082481
Doctor Name Worker Code
Nama Klinik & KLINIK RAWATAN DR MAHMUD Nama Pekerja: ALI NADEEM
Alamat: 4452, JALAN BAGAN LUAR Worker Name
Clinic Name & 12000 BUTTERWORTH PULAU PINANG
No. Pasport: ST1831641
Address Passport No.
Jantina: MALE
Gender
Tandatangan Doktor :
Doctor's Signature
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan : 043902011
Clinic's Stamp Examination Date Employer Contact No.

Sah Sehingga/ Valid Until: 14/01/2025 3 NEW TESTS

Kod Makmal: L8AI000001 Kod Doktor: D2AS000047
Laboratory's Code Doctor's Code
No Telefon: 045489614 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631714
Nama Makmal & INTEGRATED REFERENCE Nama Klinik & KLINIK RAWATAN DR Trans ID
Alamat: LABORATORIES SDN BHD Alamat: MAHMUD Kod Perkerja: W6AA082481
Laboratory's NO. 17, 1ST FLOOR Clinic Name & 4452, JALAN BAGAN LUAR Worker's Code
Name & Address LORONG PERDA UTAMA 9 Address 12000 BUTTERWORTH PULAU
Nama Pekerja: ALI NADEEM
BANDAR PERDA PINANG
14000 BUKIT MERTAJAM Worker's Name
PULAU PINANG
No. Passport: ST1831641
Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan:
Clinic's Stamp Examination Date

Sah Sehingga/ Valid Until: 14/01/2025

Kod X-Ray: X7AL000003 Kod Doktor: D2AS000047

X-Ray's Code Doctor's Code
No. Telefon: 043328146 No Telefon: 043334652
Telephone No. Telephone No. ID Trans: 20241216631714
Nama Fasiliti LING KLINIK Nama Klinik KLINIK RAWATAN DR Trans ID
X-Ray & Alamat: 4220, JALAN KAMPONG & Alamat: MAHMUD Kod Pekerja: W6AA082481
X-Ray's Facility BENGALI Clinic Name 4452, JALAN BAGAN LUAR Worker's Code
Name & 12200 BUTTERWORTH PULAU & Address 12000 BUTTERWORTH PULAU
PINANG PINANG Nama Pekerja: ALI NADEEM
Address Worker's Name

No. Pasport ST1831641

Passport No.
Tandatangan Doktor : Jantina: MALE
Doctor's Signature Gender
Cop Klinik : Tarikh Pemeriksaan: No. Telefon Majikan: 043902011
Clinic's Stamp Examination Date Employer Contact No.
Page: 2/2