Patient Registration Form Patient Registration Form v2 Personal Details First Name * Last Name * Date of Birth * Gender * Male Female HKID / Passport Number * Email * Mobile Tel * Mailing Address * Emergency Contact Name (Contact 1) * Relationship * Mobile Tel * Name (Contact 2) Relationship Mobile Tel Consent to receive medical information by E-mail • I consent to receive test results and information relating to my medical care by E-mail• I understand internet communications cannot be guaranteed to be secure or error free * Yes No Consent for our clinics to receive a copy of your previous medical records On occasion our doctors may need to review your medical records, reports and/or results that have been carried out by other providers. There could be important information pertinent to your current problem contained in them. Which other doctors have you seen in Hong Kong? ConsentI authorise Central Health to request and receive (verbal or otherwise) medical records, reports and/or results from other medical centres, specialists, imaging centres or hospitals in relation to my/my child’s care * Yes No I consent to receive clinic updates from Central Health * Yes No I consent for Central Health (Hong Kong) to share/receive my medical records with Central Health London (UK). * Yes No Insurance Payments * I acknowledge that Central Health has entered into billing arrangements with several insurers whereby Central Health will directly invoice the insurer for payment. To enable these arrangements to operate efficiently I agree that it is my responsibility to ensure that my insurance policy covers the full cost of medical services to be billed in this way. * I confirm that if my insurer refuses to settle all or part of any fees and charges due to Central Health for any services provided to me or any of my family members I will make full payment of all outstanding fees within 30 days of being notified by Central Health of the amount due. Signature Clear Privacy Statement Central Health will only collect information that is necessary and relevant to provide you with optimal medical care and treatment. Our staff will only access information if it is necessary to fulfil their role in your healthcare. All staff members sign a comprehensive confidentiality agreement and receive regular training on data protection.Your personal information will be used only for the purposes of providing medical treatment, contacting you, payment services or in ways you would reasonably expect for your ongoing care. For example, the disclosure of blood test results to your specialist or request for x-rays. We will also use your information for appointment reminders or newsletters. You may opt out of these services at any time or request to obtain copies of your medical records by emailing enquiries@centralhealth.com.hk. Should you have any questions about how your information is managed please send your enquiries to cgc@centralhealth.com.hk Reset Register If you are human, leave this field blank. Back to Home
