Request edit access
社區復康服務 物理治療師 - 網上預約登記
Community Rehabilitation Service Physiotherapy - Online Pre-Registration Form
姓名 Name *
Your answer
性別 Gender *
年齡 Age
聯絡電話 Contact Mobile Number *
Your answer
電郵 Email Address
Your answer
請選擇約見地點 Preference of Service Location *
可選多於一項 You can select more than one option
是否已備註冊西醫轉介信? *
請選擇約見時間 Preference of Service Time *
每次診症是否需有人協助陪同? *
每次診症是否需要輔助器材協助? *
其他資料或查詢 Other information or enquiry
Your answer
如何得悉本中心的物理治療服務 ? How do you know our service?
可選多於一項 You can select more than one option.
閣下所提供之個人資料只供內部作存檔之用,一切資料,絕對保密。All information will be kept confidential.
收到您的資料後,社區復康服務職員將於3個工作天內與閣下聯絡,並安排治療時間,謝謝。
After receiving your pre-registration information, our staff will contact you within 3 working days to arrange an individual therapeutic appointment. Thank you.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy