健康管理中心客戶預約表

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健康管理中心客戶預約表

Cheng Hsin General Hospital Health Management Center Reservation Form

*Required

預約姓名 Subscriber’s Name *

性別 Gender *

女 Female

男 Male

出生日期(西元)年/月/日Date of Birth(CAD) Year/Month/Day *

是否曾在本院就診 Have you ever seen a doctor in our hospital? *

是 Yes

否 No

國籍 Nationality *

中華民國 Republic of China，Taiwan

Other:

中華民國身分證號/居留證號(若無請填護照號碼)Republic of China ID card No./Resident Certificate ID No. (If you don’t have one, please fill in the Passport No.) *

行動電話(若無請填市話)Mobile phone number (If you don’t have one, please fill in a local phone number) *

電子信箱E-MAIL(若無請填無) (If you don’t have one, please fill in None) *

體檢包寄送地址Health examination kit mailing address *

希望預約日期 About the appointment date *

一個月內 Arrange Within one month

Other:

您想預約的健檢專案 The package I'm interested in *

尚未確定需要進一步諮詢 Need further consultation.

微型健檢專案 Compact Health-check Package

超值型健檢專案 Value Health-check Package

一般型健檢專案 General Health-check Package

心臟型健檢專案 Cardiac Wellness Health-check Package

腸胃型健檢專案 Gastrointestinal Endoscopy Health-check Package

全身高階磁振防癌型健檢專案 Whole Body MRI Cancer Screening Package

白金防癌護心型健檢專案 Premium MRI & Heart Health-check Package

鼎級全方位健檢專案 Top-end Health-check Package

公教人員(現職)健檢專案 Government Employees and Teachers Health Check Package

簽約團體健檢專案 Company Group Health Check Package

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