請於入院前最少一個工作天完成網上登記程序

Please submit this admission form at least one day prior to your admission to allow time for preparation

Online Admission Form Date : 20-07-2008

Section 1 (Client's Details)

姓名 Surname as on I.D. Card:   名 / 別名 Given Names :

婚前姓名 Maiden Name :   性別 Sex : -- M F   出生日期 Date of Birth : (Day) (Month) (Year)

國籍 Nationality :   宗教 Religion :

身份證號碼 / 出生証號碼 / 護照號碼 H.K.I.D. No. / Birth Cert. No. / Passport No. :   簽發國家及日期 Date & Place of Issue :

病人職業 Occupation :   僱主 Employer :

地址 Home Address :

電郵 Email Address :   電話 (住宅) Tel No.   手提 Mobile :

預定入院日期 Expected date of admission : 醫生 Admitting doctor :

緊急聯絡人 Emergency Contact Person :   與病人關係 Relationships :

身份證號碼 / 護照號碼 H.K.I.D. No. / Passport No.:   緊急聯絡電話 Emergency Contact No.

職業 Occupation :   僱主 Employer :

Section 2 (Method of Payment) (付款方法)

Cash 現金 EPS 易辦事 Credit Card 信用卡 Insurance A/C 醫療保險 Corporate A/C 公司賬戶 Other 其他

(1) I understand that I will automatically be enrolled on a package if one is available. Any extra items or additional day not included in the package will be charged separartely. 本人明白如有適用之套式計劃，本人將自動登記入該計劃內。套式計劃內不包括之額外項目及超出計劃內所包括之住院日數，將會額外收費。 (2) I, the undersigned, accept full responsibility for the settlement of all expenses incurred by the patient. 本簽署人全權負責支付以上病人之一切費用。 (3) I have read and agree to the terms and conditions detailed on the "Admission Information Sheet". 本人已閱讀及同意"住院需知守則"上的一切條款。 We will periodically send you hospital and medical information. If you would like to receive such information, please tick the box. 我們會為閣下定期寄上本院及醫療資訊。如閣下同意，請於方格上填上剔號。