Clinic > Client Registration Form 登記表

Client Registration Form 登記表

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Demographic Information 個人資料

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.

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。
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。

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。