The case of the skin and bone poodle. No more daily vomiting. Shall I cut to 3 meals a day?

"No more daily vomiting. Shall I cut down to 3 meals a day?" the wife asked.
"My dog only vomits when he is let free and he rushes out to eat the grass or late at night. I leash him and stop all feeds after 7 pm. So, my dog does not vomit at other times and is putting on weight. Shall I cut down to 3 meals a day instead of 2-3 hour daily from 9 am to 7 pm?"

"No," I said. "Your dog has a megaoesophagus condition and can't eat in large amounts." The lady probably could not understand what I was saying. Mega what?

I explained again: "Your dog's gullet near the stomach area is paralysed and enlarged. So food is trapped in that area instead of going straight into the stomach like normal dogs. The food accumulates and if in large amounts, together with drinking water, can get 'vomited' out."

Actually the dog regurgitates but it is hard to explain this to the elderly couple. If they feed 3x/day, the poodle would not put on weight. Now, she is still skin and bones but feel heavier.

The owner has to feed small amounts more than 3 times a day if she wants the dog to live. There is no surgical to resolve the problem now. In any case, there is a need for more investigation but the elderly couple needs to save up for their daily expenses. The money they spent on educating two children overseas to become high earners in society have been losses since now they have to be frugal.

Many middle-income parents do sacrifice so much that they start counting pennies when their pets need treatment. It can't be helped as they don't like to ask their children for money. Even though such children earn 10 times more than what they earn!



http://www.sinpets.com/dogs/20110215megaoesophagus-follow-up-toapayohvets-singapore.htm
has the previous case reports

386. "Your intern has run away!" my assistant said.

"Your intern has run away!" my assistant Mr Saw said to me on Monday when I came back from my RES course of 3 hours in the morning on Monday, Wednesday and Friday for 2 months. Mr Saw considers interns as pests wasting his time to teach them but he obliges when I ask him.

The young bespectacled short lady from Tampenis Junior College had phoned me for an internship as she was offered a place in the BioMedical course in Murdoch University on the introduction of Mr David Teo, a campus recruitment agency.

I told her to come on Sunday April 4, 2011 at 10am to try out one day and to be interviewed. Her father dutifully drove her to the Surgery at 9.30 am.

Her A level results did not qualify her to study veterinary medicine at Murdoch University. "3 As are needed," she said. "If I do very well in the BioMedical Course, I can join the 2nd year of Veterinary Medicine."

I reviewed her background. She had done some voluntary work at the SPCA cleaning the kennels and handling dogs. However, there was no documentary proof. "Are you sure you want to study Veterinary Medicine? You will need to study very hard and be top in the Bio-Medical course to get into the 2nd year. Nothing less than that." I asked her again. "Can your family afford to pay $300,000 for the course?"

She had better O level results than her A level. Something happened during her 2nd year of Junior College adversely affecting her academic performance. There are many young ladies from brand-name schools with unbelievable straight As. The last lady I spoke to had 6As and would have qualified to study veterinary medicine. If only her parents have the money. Yet this girl said her father could support her.

Well, I gave her an opportunity to work as an intern. She worked with Dr Vanessa on a busy Sunday afternoon. The next day, she did not turn up. Nor did she phone to thank me or said goodbye.

Sometimes I wonder why I should bother with giving 2nd chance to young people who don't make the grade to study veterinary medicine overseas?

385. Post-neuter complication - dog traumatises scrotal area

385. Post-neuter complication - dog traumatises scrotal area
Feedback from a client improves the standard of care

E-MAIL FROM DR SING DATED APRIL 5, 2011 4,52 am

I am Dr Sing from Toa Payoh Vets. We spoke by phone yesterday afternoon. Give the 3 tolfedine tablets before midnight and observe. It is easier to communicate by phone than by texting a reply to your iphone.

I saw your picture of the dog's scrotal bruising in my phone but since we had just spoken by phone, I did not text a reply back. The dog has been traumatising its scrotal area using the e-collar.

This self-inflicted bruising is one of the post-operation complications seen in a one or two male dogs out of 100. In your dog, the traumatised scrotal skin is not serious presently as it is just 24 hours post-neuter.

Your dog had been given tolfedine pain-killer injection after surgery yesterday morning (Apr 3, 2011). You gave the tolfedine tablets at 4.30 pm on Apr 4, 2011 and noted the redness in the scrotal area. It is good that you e-mail the picture of the site as I thought it was the operation area (which is covered by the plaster) that was bleeding.

As advised, please give 3 tolfedine tablets orally 8 hours after 4.30 pm (your first dose).
Normally, the pain killer should be sufficient but your dog needs twice a day instead of once. Please let me know if your dog needs more pain-killers as normally, I prescribe for around 3 days including the injection post-surgery. Your dog may need an injection if he further traumatise his scrotal area. If not, the redness will fade over 2 weeks. Pl phone me when you have queries as it is much easier to talk than to thumb.

Best wishes.
REVIEW
A small number of male dogs of around 1 in a hundred traumatise their scrotal area after neuter despite being given pain-killer injection post-neuter and oral tablets at home.

In this case, the owner gave the tablets at 4.30 pm, around 24 hours post-surgery. In future, all pets should be given the pain-killers in the morning, ie. 12 hours post-surgery twice a day. Tolfedine is recommended by the manufacturer to be given once a day for a maximum of 4 days. 4 days on, 3 days off schedule. Some vets prefer other brands of pain-killers.


E-MAIL TO DR SING DATED APRIL 6, 2011

Dear Dr Sing

Thank you for your note. We'll continue to observe XXX's conditions over the next few days and contact you again when necessary.

I would also like to highlight that we're very disappointed and frustrated over all the unclear and confusing verbal communications.

When we first pick up XXX post his op, I asked your clinic assistant specifically "when should we feed the medication - morning, afternoon or night? before or after meal?" He said "doesn't matter, just feed once a day."

When we spoke with you last evening, you said specifically "2 tablets 10pm+ or before midnight and 2 tablets again next day morning." which I did feed him 2 tablets at 10pm last night and 2 tablets again this morning. I've 2 tablets left which I'll feed him again tonight.

I believe if XXX is traumatising its scrotal area, its due to itch from the stitches or plasters (which was already loosely attached when we pick up XXX post op). Again, I asked your clinic assistant "when should we remove the plasters or do we need to change to a new one and do we need to bring XXX back to remove stitches or is it the dissolve-able type?" He said "leave the plasters on for next 1-2 days before removing it and don't really need to remove stitches but should bring XXX back to see you in 2 weeks time." which you advised last evening when we spoke "to change a new plaster and leave it on."

Hence, I've a few questions to re-clarify:
1. are the stitches dissolve-able type? if so, is there still a need to see you in 2 weeks time?
2. or if its not, is there any additional charges to remove the stitches on top of the premium price that we've already paid?
3. do we continue to change the plasters when it come loose and leave it on till we see you in 2 weeks time?
4. or can we remove it totally in the next few days?
5. the collar can be removed in 2 weeks time right?
6. both the yellow and pink medication bottles must be fed completely right?

When we first called to inquire about the price, we're advised its $150+ which the final bill came up to a shocking $350+ before you kindly removed the blood test charge of $100 (originally $150 before discount as advised by your clinic assistant) as we did not ask to conduct a blood test. We also found out the general clinics' market rate is $80-$100 for blood test and $5 for the collar which we've been charged $20. I can only hope that the premium price we've paid for is for return of high quality products and professional services to make this whole process most comfortable for XXX's well being.

Appreciate if you can revert on our queries above.

Regards
E-MAIL REPLY FROM DR SING DATED APRIL 6, 2011

It is best to talk directly if you need clarification, whether over the phone or in person. However, I will try and reply to your email queries as detailed as possible below in CAPITAL LETTERS. 


On Tue, Apr 5, 2011 at 3:13 PM, ...gmail.com> wrote:

Dear Dr Sing


Thank you for your note. We'll continue to observe XXX's conditions over the next few days and contact you again when necessary.


I would also like to highlight that we're very disappointed and frustrated over all the unclear and confusing verbal communications.

I HAVE SPOKEN TO MY STAFF MR SAW.

When we first pick up XXX post his op, I asked your clinic assistant specifically "when should we feed the medication - morning, afternoon or night? before or after meal?" He said "doesn't matter, just feed once a day."

IN MOST CASES, ONCE A DAY IS THE CORRECT ANSWER AS I HAVE HAD GIVEN THE ANTIBIOTICS AND PAINKILLERS THE AFTERNOON BEFORE. THE NEXT TIMING SHOULD BE 24 HOURS LATER.

I HAVE TOLD MY STAFF TO BE MORE SPECIFIC AND SAY IN THE MORNING. 


When we spoke with you last evening, you said specifically "2 tablets 10pm+ or before midnight and 2 tablets again next day morning." which I did feed him 2 tablets at 10pm last night and 2 tablets again this morning. I've 2 tablets left which I'll feed him again tonight.


I believe if XXX is traumatising its scrotal area, its due to itch from the stitches or plasters (which was already loosely attached when we pick up XXX post op). Again, I asked your clinic assistant "when should we remove the plasters or do we need to change to a new one and do we need to bring XXX back to remove stitches or is it the dissolve-able type?" He said "leave the plasters on for next 1-2 days before removing it and don't really need to remove stitches but should bring XXX back to see you in 2 weeks time." which you advised last evening when we spoke "to change a new plaster and leave it on."

IF PLASTER IS LOOSE, IT NEEDS TO BE CHANGED. THE PLASTER IS TO FURTHER PREVENT THE DOG FROM LICKING THE WOUND AND STITCHES  

Hence, I've a few questions to re-clarify:
1. are the stitches dissolve-able type? if so, is there still a need to see you in 2 weeks time?

NO NEED TO SEE ME TO REMOVE THE STITCHES AS THEY ARE ABSORBABLE. STITCHES WILL DISSOLVE IN 14-28 DAYS TIME. BUT IN SOME CASES, THE STITCHES DO NOT DISSOLVE IN 14 DAYS' TIME AND THE DOG IS IRRITATED BY ITS PRESENCE, I ASK THE OWNER TO COME AND GET THEM REMOVED FREE OF CHARGE.
 
2. or if its not, is there any additional charges to remove the stitches on top of the premium price that we've already paid?

NO ADDITIONAL CHARGES

3. do we continue to change the plasters when it come loose and leave it on till we see you in 2 weeks time?

CHANGE THE PLASTER WHEN IT IS LOOSE OR DIRTIED
 
4. or can we remove it totally in the next few days?

IN SOME CASES, YES. MUCH DEPENDS ON THE DOG'S SENSITIVITY TO HAVING A PLASTER ON. I CANNOT BE SPECIFIC AS EACH DOG BEHAVES DIFFERENTLY AFTER SURGERY, TOWARDS THE PAIN AND IRRITATION OF WOUND HEALING
 
5. the collar can be removed in 2 weeks time right?
PREFERRED BUT IN SOME CASES, 1 WEEK WILL DO. MUCH DEPENDS ON THE DOG'S BEHAVIOUR TOWARDS WOUND HEALING. SOME DOGS ARE VERY SENSITIVE AS WOUND HEALING AREA IS IRRITATING BUT SOME DON'T BOTHER.
 
6. both the yellow and pink medication bottles must be fed completely right?
YES

When we first called to inquire about the price, we're advised its $150+ which the final bill came up to a shocking $350+ before you kindly removed the blood test charge of $100 (originally $150 before discount as advised by your clinic assistant) as we did not ask to conduct a blood test.

AS YOU DID NOT WANT THE BLOOD TEST TO BE DONE, MY ASSISTANT SHOULD DEDUCT $150. IF NOT, I WILL REFUND YOU BACK BY CHEQUE $50. I WILL ASK HIM TODAY.
 
We also found out the general clinics' market rate is $80-$100 for blood test and $5 for the collar which we've been charged $20. I can only hope that the premium price we've paid for is for return of high quality products and professional services to make this whole process most comfortable for XXX's well being.

MARKET RATE FOR BLOOD TEST VARIES. YOUR BLOOD TEST IS A COMPLETE BLOOD TEST WHICH INCLUDES HAEMATOLOGY AND TESTS INCLUDING THE FUNCTIONS OF LIVER, KIDNEY, BONES AND JOINTS, GLUCOSE LEVEL. IT IS NOT POSSIBLE TO COMMENT FURTHER BASED ON PRICES OF COMPETITORS. AS FOR THE E-COLLAR, PRICES VARY AND IT IS BEST YOU PHONE ME IF YOU WISH TO DISCUSS FURTHER THE PRICING.

YOUR DOG'S REACTION TO NEUTER IS NOT COMMON BUT DOES HAPPEN IN 1 OUT OF 100 CASES. IT IS NOT SERIOUS AS HE HAS THE PAIN-KILLER TOLFEDINE. TOLFEDINE IS RECOMMENDED TO BE GIVEN ONCE A DAY FOR 4 DAYS ON, 3 DAYS OFF. SINCE YOUR DOG HAS SENSISTIVITY TO PAIN, I ADVISED TWICE A DAY ON THE DAY YOU PHONED.

I HOPE ALL ARE WELL WITH HIM NOW. PL PHONE RATHER THAN TEXT AS IT IS MUCH CLEARER TO TALK THAN TO WRITE AS MISUNDERSTANDINGS ARE LIKELY TO OCCUR DURING WRITING. 


E-MAIL TO DR SING DATED APRIL 7, 2011
Thanks for your notes. It's very helpful info and clarifies. There's no need for refund of blood test as all blood test charges has been taken out at point of payment.
E-MAIL FROM DR SING DATED APR 6, 2011

I spoke to my assistant whose last day is today. He said that it was $100 which was charged in the bill but had been taken out.

I appreciate your feedback as that is the most important way to improve my standard of management and service. There is no other way as the practice learns from experience and mistakes made. The best feedback are those that I have made mistakes. Will update instructions post-surgery to all my vets with a standard form now. Pl accept my thanks.
E-MAIL TO DR SING DATED APR 6, 2011

I hope my feedback didn't cause Mr Saw his job, that will be too harsh.

Good thinking, I'm sure your clients will appreciate a standard FAQ surgery fact sheet for their reference. This should save you answering repetitive queries and able you to focus on other matters.

Regards

We will continue to observe XXX's recovery from here.

E-MAIL FROM DR SING DATED APRIL 7, 2011

Thanks for your feedback. Mr Saw completed his 3-year contract. He has better prospects of starting his own practice in Yangon. He has had done an excellent job during his employment and left on very good terms with his employer. I will be doing the surgery fact sheet with my two other associate vets as all 3 of us have different post-operation nursing care and advices. For example, I use plaster to cover the surgical wound to prevent it from being contaminated by the environment and licking by the dog or cat. My associate vets do not but use the e-collar.

I hope your dog is OK now. Thank you.
CONCLUSION

The vet usually explains the risks and post-operation complications. The owner is also asked to sign the Toa Payoh Vets' Informed Consent Form to confirm he or she has been informed of the risks and complications.

Risks refer to the anaesthetic risks. Therefore a blood test is advised to confirm that the dog is healthy. Post-operation complications are pain, bleeding and infection and are listed in the Informed Consent Form.

In 99% of the neuter and spay cases in my 30 years of small animal practice in Toa Payoh Vets, there have rarely been complaints of post-op complications at Toa Payoh Vets as I prescribe antibiotics and pain killers post-surgery. I do have a post-surgical information fact sheet but it has not been given as a routine.

A very small number of dogs have low tolerance to pain after neuter or spay. Some vets even give pain-killer injections before surgery as well as after. A post-surgical advice sheet will be best.

I will get this post-operation complication advices information incorporated in the spay or neuter certificate to be printed officially and signed by the owner so that the information has been read and is always available for family members.

Phoning the vet at Toa Payoh Vets is still the best way to get answers to queries of post-op complications although text messages and e-mails to me are very common with the younger generation.

THE WEBPAGE IS ALSO AT:

http://www.kongyuensing.com/folder5/20110325Trauma_self-inflicted-scrotal-post-neuter-dogs-surgery-toapayohvets.htm

384. Dental Scaling E-mails to Toa Payoh Vets

E-MAIL TO DR SING DATED MAR 26, 2011
Subject: Scaling for dogs
To: judy@toapayohvets.com
Received: Friday, 25 March, 2011, 2:00 PM

Hi,

I am looking for a trusted vet and doctor who can perform scaling on my 2 year old Chihuahua. I am interested upon sending her to Toa Payoh Vets. I would like to know how much it would cost and what I should do to prepare her for the day of her visit.

Thank you,
Name given


E-MAIL REPLY TO DR SING
DATED MAR 28, 2011
Thank you so much. 

E-MAIL REPLY FROM DR SING DATED MAR 26, 2011
Hi

I am Dr Sing from Toa Payoh Vets. Thank you for your email to Judy.

The dental scaling plus anaesthesia cost is around $250 normally. Decayed tooth extraction will be around $10-$20 per tooth extracted. Medication of antibiotics and pain-killer is estimated at around $20 if necessary. Blood test for pre-anaesthesia risk checking will not be done in normal healthy dogs and will cost $150 if it is needed but you will be informed first.

Do not feed or give water to your dog after 10 pm the night before the dental work. Bring your dog to Toa Payoh Vets at 10 a.m. The dog will go home around 5pm usually, after rest and recovery from general anaesthesia.

Please make an appointment at 6254 3326. Please indicate which vet you prefer. These are Dr Sing, Dr Vanessa Lin and Dr Jason Teo.

Fools rush in where angels fear to tread - A hamster's large neck tumour

SURGICAL AREA
A big soft lump from below one ear to another and dangling under the neck in an old Syrian hamster (female, 20 months). This is the type of surgical condition I dread most. Performing this type of surgery is "fools rush in where angels fear to tread". The neck area has many important nerves, arteries and veins and it is not a very dangerous area to remove tumours especially in a hamster. That area below the throat is so small (less than 1 cm) compared to a dog or cat. A few thousand times smaller. There is no luxury of using an operating microscope and in any case, the surgery must be short as the hamster can't survive long anaesthesias of more than 1 minute, in my experience. You can't top up anaesthesia as in the dog and cat. Any more anaesthesia, the hamster just dies.

ANAESTHESIA
Very risky in a lethargic hamster. That means the hamster is not normal and healthy. The owner of this case waited till the neck tumour becomes very large. Is it inoperable? In any case, the chances of the old and lethargic hamster surviving are much lower. Less than 10%. So why take the case and risk damaging one's hard-built reputation as a "killer" of hamsters when this Syrian hamster dies on the operating table? Why not pass the buck to other vets?

DOSAGE OF INJECTABLE ANAESTHESIA IS HARD TO CALCULATE
"How much to give?" I asked my assistant Mr Saw (as part of my training of the past 3 years with me). He will be going to greener pastures in 2 weeks' time. "One drop of Zoletil will do," Mr Saw said. The owner had already said the hamster was lethargic for the past 2 weeks and the lump had exploded to big size during this time. Therefore, minimal dose as recommended by Mr Saw was the correct thing to do.

I gave one drop of Zoletil by injection IM into the left backside muscle. Waited for 5 minutes. The hamster looked at me and behaved normally, walking around inside the plastic container. She ought to be sleepy but she was much wide awake.

I waited another 5 minutes. She was active and had produced more faecal pellets. So, this dosage given was not effective. "In Syrian hamsters (160g), you need to give 4 times the dosage of a dwarf hamster (40 g)," I said to Mr Saw. But how do you calculate the dosage? It is easy in dogs and cats because they weight in kg when adult. But in this adult old hamster, she was 160 g.

"Give 2 drops," I asked Mr Saw to prepare the Zoletil. He filled up Zoletil 100 in one one-ml syringe and then push out one drop from its tips. Then I should use another one-ml syringe with a fine needle to aspirate the two drops.

"Hey, it is better you rest your elbows on top of the operating table," I said as it is hard to be precise in the present set up. "I also put my hands on top of the table." I then used the tip of my 25G needle attached to my one-ml syringe and aspirated two full drops from Mr Saw's one-ml syringe tip.

I injected into the right backside muscle. Within one minute, the hamster was lying down on his back.

So far, the Providence had been kind to me. The hamster was down but not out. Not dead I mean.

IV DRIPS
Impossible to do in a hamster. The veins are too small. SC injection of up to 3 ml dextrose saline is possible and was done in this case post-op.

SURGERY
After being sedated with the correct, safe and effective amount of Zoletil 100, the hamster went down sideways. There was a window of analgesia for around 1 minute to get the lump excised and the skin sutured.

I incised the skin 1 cm. A glistening membrane of the lump appeared under the skin. It seemed to be cyst but it was not 100% fluid filled lump. I saw a large vein from the lump (see illustration). "Is it the jugular vein?" I asked Mr Saw to make him think. He kept quiet. We had never seen jugular veins in hamsters in previous surgeries. Well, this location of the tumour was the second one I encountered during the past years of practice.

Know your anatomy well. It was not the jugular vein. I was just making my assistant think about hamster anatomy. He photocopied many veterinary notes and illustrations to prepare himself for the setting up of a private practice in Yangon later in the year. But nothing beats photocopies like seeing the real thing.

"Is it the jugular?" I asked my assistant again. He did not reply. It certainly was the biggest widest blue vein we had seen under the neck but it was connected to the tumour some below the tumour mass. It was unlikely to be a jugular but since the neck area is so small in size compared to that of a dog or cat, it would be hard to discount its presence. As a guideline, any large vein connected to a big tumour would be a feeder vein and the artery would be next to it. The tumour needed more nutrients and the blood vessels seem to enlarge to supply the ravenous growth.

I clamped the tumour and excised. Immediately blue blood spilled out. This vein was hard to ligate initially as it was very close to the pharynx. I dared not ligate as the needle might perforate the pharynx. So I excised the tumour first. Around 3 ml of blood splashed out. "Swabs," I said. Mr Saw provided the 3 swabs I needed to clear the bloodied area. I could see the bleeding vein. Ligated it. Then another big spurt appeared. It was probably the artery injured during the first ligation. I ligated this second bleeder. No more bleeding.

"Stretch the 2 cm skin wound by putting your thumb and index finger on either side," I said to my assistant. In this way, the skin wound is stretched out and I could appose the cut skin with 3 horizontal mattress sutures quickly. The hamster's neck was not straight in this type of surgery. No luxury of tying up 4 legs and positioning the head on a pillow as in the dog surgery. The hamster was just too small to do all these. Time is of the essence. Surgery must be short.

My assistant said as I cut out the bits and pieces of this mixed tumour and started wiping off the large amount of blood from below the eyes to shoulder: "Stop, I can clean the blood off later. The hamster is going into shock soon. Stop and wait. Do not stress the hamster."

I tried to clean up as much blood as possible as bacteria from the surrounding will infect the hamster via this outside blood.

The hamster started panting. Breathing at more than 100x/minute. Why? Stress had set in. Was she going to die?

My 2nd assistant took out a hair dryer, set to lowest warmth and warm up the hamster. "Give 3 ml of dextrose saline SC," I asked Mr Saw to stop as he started to get normal saline. It was not possible to give an IV catheter as in the dog because it is practically impossible to get a hamster's vein and I doubt if anybody can do it. The hamster is just so small and everything is miniaturised. So subcutaneous fluid was OK. But it must be dextrose saline in my opinion and this can be given by SC. Glucose itself cannot be given SC.

As everything was so tense, the vet must have a clear mind and ensure that proper drugs and saline are given by being observant.

After an eternity of more than 30 minutes of being kept in a warm room, the hamster breathed normally. I took a photo of her trying to stand up. It was a good sign. In 24 hours, I took her photograph and was glad that she was alive. Not all stories end happily all the time for all vets. It is best for owners to check their older hamster early for small tumours. These are easier to remove and take a much shorter time.

More pictures are at www.toapayohvets.com. Click HAMSTERS

For more pictures of the surgery: goto

http://www.sinpets.com/F6/20110323massive-neck-tumour-syrian-hamster-surgery-toapayohvets.htm

Spay guinea pigs

REPLY TO AN E-MAIL QUERY

We do sterilise female guinea pig. Cost is from $250 - $300. Pl make appointment with Dr Sing at 6254 3326. The guinea pig must be at least 6 months old and be healthy. Pl note that there is always a risk of death from anaesthesia in any surgery in guinea pigs and other animals.

381. Hamster injuries can be infected

E-MAIL TO DR SING DATED MAR 31, 2011

2011/3/31 ...@hotmail.com>

Hi there,
I own a hamster which was previously owned by two different owners. When the hamster was taken care by the 1st owner, she placed him with another hamster which bit him. He was then given to the 2nd owner, whose mother didn't want her to keep him, so she gave him to me.
The problem is that he has bumps on his ear and around his eye. Over time his eye got worse and it covered his whole eye thus, now he is blind in one eye.
Should I bring him for a check up?
Name of owner



E-MAIL FROM DR SING DATED MAR 31, 2011
Date: Fri, 1 Apr 2011 07:43:21 +0800
Subject: Re: About my hamster
From: 99pups@gmail.com
To: ,,,@hotmail.com

Yes. Pl make an appointment at 6254 3326 to see Dr Sing at 9.30 am or let the receptionist know.