瞳訊會員登記表 VMed Membership Registration
請提供閣下之基本資料,瞳訊會因應閣下的情況和需求安排往就近的篩查點接受篩查。謝謝!閣下在此提供的個人資料將受私隱條例保護。 Fill out the form with your personal information Visiona will arrange for you a screening service point based on your needs and preferences. Personal information collected here is subject to the protection of Privacy Laws. Thank you!
Email address *
男/女 Male/Female *
Required
年齡層 Age Group *
Required
最方便你接受篩查服務的地區 Your preferred District to receive the screening?(例如:油尖旺; e.g. Central) *
Your answer
閣下是否糖尿病患者? Are you a DM patient? *
閣下糖尿病史有多少年? Years of history as a DM patient? *
閣下上一次檢查眼底是什麼時候? When did you last had your retina checked? *
閣下有直屬親人是糖尿病患者? Any of your direct relatives a DM patient? *
姓名 Name *
Your answer
聯絡號碼 (亦將是閣下的會員號碼) Contact Number (Will be used as your membership number as well) *
閣下提供聯繫號碼即表示願意接受瞳訊公司合理用作聯繫閣下以便通知隨後服務安排,我們可能以電話形式或短信(包括 WhatsApp等)。By providing your contact number, you accept implicitly Visiona will use it to contact or notify you for subsequent arrangement of services. This could be in form of phone calls or text messaging(including WhatsApp, etc.)
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service