Customer Details - VivaDiag SARS-CoV-2 Ag Rapid Test

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This form is intended for the company to maintain a record of the customer details to enable good monitoring by the Authority.

By submitting this form, you hereby agree that Convemed Sdn Bhd, may collect your personal details and disclose your personal data to the relevant governmental authorities or third parties where required by law or for legal purpose as defined within Personal Data Protection Act 2010 (PDPA).

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Management Team
Convemed Sdn Bhd
CT-09-01 Corporate Tower Subang Square,
Jalan SS15/4G, 47500 Subang Jaya, Selangor.
Tel: 03-86054677
Email: sales@convemed.com.my

Full Name as per IC *

IC number *

Phone number *

Email *

Please select the product you purchased *

VivaDiag SARS-CoV-2 Ag Rapid Test (Nasal); CA Ref No.:(54)MDA.600-1/6/27

VivaDiag SARS-CoV-2 Ag Saliva Rapid Test; CA Ref No.:(70)MDA.600-1/6/27

VivaDiag SARS-CoV-2 Ag Saliva Rapid Test (Lollipop); CA Ref No.: Pending Approval

Please select the Lot number for the product you purchased

SE2109004

SE2108080

SE2111146

SE2110014

Other:

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Purchased quantity

1 unit

2 units

3 units

4 units

more than 4 units

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Date of purchase *

YYYY

Time of purchase

Time

Where you purchase the product? *

Hospital / Clinic

Online

Pharmacy

Corporate

Others

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