Client Registration Form 登記表 – HF Connecting Health Nurse Practitioner-Led Clinic

Demographic Information 個人資料

Name 姓名 (as printed on Health Card) *

First

Last

Date of Birth 出生日期 *

Address 住址

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Primary Phone Number 電話號碼 (優先) *

Alternate Phone Number 電話號碼 (次選)

Address 住址 *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Gender 性別 *

Spoken Language 溝通語言 *

Country/Place of Birth 出生地 *

Date of Arrival to Canada 抵達加拿大日期 *

Health Card Number 安省醫療保健卡號碼 (10 digits + two letters) *

Health Card Number Expiration Date 安省醫療保健卡號碼有效日期至 *

Emergency Contact 緊急事故連絡人 *

Phone 電話 *

Relationship 關係 *

Do you currently have a family physician? 你現在有自己的家庭醫生嗎? *

Yes 有
No 沒有

Please complete for all clients with a legal guardian and for all children less than 16 years of age. 未滿 16 歲的客戶必須提供監護人資料.

Primary Guardian 主要監護人

Phone Number 電話 (家)

Phone Number (Mobile) 電話 (手提)

Phone Number (Business) 電話 (公司)

Please help us provide statistics for our program development purposes.

請提供以下資料作為統計用途,以協助我們籌劃將來的項目發展。

Please help us provide statistics for our program development purposes 請提供以下資料作為統計用途,以協助我們籌劃將來的項目發展。

Highest Educational Level Obtained 教育程度:

Combined Annual Income 家庭年度收入:

Number of People Supported by Income 家庭成員人數:

Household Composition 家庭成員組合:

Consent to email communication 電子郵件接收書面同意

By providing your e-mail address, you are giving us consent to send you electronic communications, such as calendar of events and newsletters. No personal health information would be shared via e-mail. 當閣下填寫您的電郵地址,即代表同意我們將本診所活動及刊物以電郵方式通知閣下。我們不會將閣下的個人或健康資料以電郵傳送。

Email Address 電郵地址 *

Consent to use information 資料使用書面同意
As a client of HF Connecting Health Nurse Practitioner-Led Clinic, I understand and agree my personal health information will be shared between members of the interdisciplinary health team when said sharing contributes to the continuing care and treatment. The interdisciplinary health team includes nurse practitioners, collaborating physicians, registered nurses, dietician, social worker, health promoter, psychiatrist and clinic administrators.
作為 HF Connecting Health Nurse Practitioner-Led Clinic 的客戶,我理解並同意本診所內的醫療團隊可接觸我的個人健康資料,以作為延續健康護理及診斷治療用途。本診所的醫療團隊包括執業護理師、顧問醫生、註冊護士、營養師、社工、健康推廣員、精神科醫生及行政員工。

Type Your Name Here (as e-signature) 客戶名稱(電子簽署)

Date 日期

Demographic Information 個人資料

Please help us provide statistics for our program development purposes.

請提供以下資料作為統計用途,以協助我們籌劃將來的項目發展。

Annual Reports