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Application for JCHH services 賽馬會善寧之家服務申請
Patient 病者
Name 姓名 (Chinese 中文) *
Please input "na" if you do not have a Chinese name
Name 姓名 (English 英文)
HKID 身份證號碼
Sex 性別 *
Age 年齡
Date of Birth 出生日期 *
MM
/
DD
/
YYYY
Contact no 電話
Address 地址
Did patient apply for Electronic Health Record (eHR)? 病人是否已登記電子健康紀錄? *
Please use the link to apply for eHR 請使用以下連結申請電子健紀綠
https://goo.gl/Hm9HJ8 (English Version) https://goo.gl/ttoz9x (中文版本)
Applicant 申請人
Name姓名(Chinese中文) *
Name姓名(English英文)
Relationship with patient 與病者關係
Contact no電話
Address地址
Email Address 電郵地址
Service(s) expected from JCHH (More than one alternative is allowed) 期望本院舍提供之服務 (可選多項): *
Required
Select preferable time-slot(s) for our palliative nurse to call back(More than one alternative is allowed)由紓緩科護士回電的適合時間 (可選多項): *
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