1. 歡迎填寫我們的申請表!
Welcome to fill in our application form!

本公司遵守<<個人資料(私隱)條例>>, 閣下所提供的個人資料將會受到保密。我們從閣下所收集的資料將用作研究、與閣下聯絡、業務發展的目的和/或其他附帶和輔助的目的。 如閣下不提供閣下的個人資料，我們可能無法為閣下提供我們的服務。 此外，我們可能會與我們的研究合作夥伴分享閣下的信息。
We comply with the Personal Data (Privacy) Ordinance, your personal information will be kept confidential. The information collected from you will be used for the purpose of our research, future communication with you, business development and/or other incidental and ancillary purposes. In the event that you do not provide such personal data, we may not be able to provide you with our services. Further, we may share your information with our research partners.

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* 1. 填寫人中文或英文姓名 (例如: 陳大文/ Chan Tai Man)
Your Chinese or English Name (e.g. 陳大文/ Chan Tai Man)

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* 2. 填寫人電話號碼
Phone Number

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* 3. 與患者的關係
Relationship with Patient

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* 4. 患者中文姓名 (例如: 陳小明)
Patient's Chinese Name (e.g. 陳小明)

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* 5. 患者英文姓名 (例如: Chan Siu Ming)
Patient's English Name (e.g. Chan Siu Ming)

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* 6. 患者年齡
Patient's Age

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* 7. 患者性別
Patient's Gender

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* 8. 患者出生日期
Patient's Date of Birth

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