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Appointment Form

预约单

The form is for you to make an appointment online for international medical servicess

请您填写以下表单,用于预约国际医疗服务

Name/姓名:(If you have insurance card, your name must be consistent with that on your insurance card.)

Gender/性别:

Date of Birth/出生日期:

Nationality/国籍:

Medical Insurance No./医保账号:

E-mail Address/电子邮箱:

ID or PassportNumber/身份证或护照编号:

Phone/电话:

Present Address/现居地:

Appointment Date/预约日期:

Appointment Time/时间:

Short Description of Your Complaints/主要症状与体征:

Medical History/病史:(Such as Hypertension Diabetes/Allergy of Food or Medication/Non Special/other)

Medications you are taking/正在服用的药物(Please declare no when you are not taking any medication)

Special Needs/特殊需求:Such as a wheel chair/language support except English

*Your information will absolutely be kept confidential. Please bring your photocopies of your passport and insurance card (both sides copy needed) if you have medical insurance.

* 您的就医信息将被严格保密。如您有医疗保险,请携带您的护照和保险卡复印件(双面复印)