Application for JCHH services 賽馬會善寧之家服務申請
Patient 病者
Name 姓名 (Chinese 中文) *
Your answer
Name 姓名 (English 英文)
Your answer
HKID 身份證號碼
Your answer
Sex 性別 *
Age 年齡
Your answer
Date of Birth 出生日期 *
MM
/
DD
/
YYYY
Contact no 電話
Your answer
Address 地址
Your answer
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) *
Your answer
Name 姓名 (English 英文)
Your answer
Relationship with patient 與病者關係
Your answer
Contact no 電話
Your answer
Address 地址
Your answer
Email Address 電郵地址
Your answer
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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