Visa Medical Examination Appointment System

Applicant 申請人 1

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書

Applicant 申請人 2

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書

Applicant 申請人 3

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書

Applicant 申請人 4

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書

Applicant 申請人 5

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書

Applicant 申請人 6

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書

Applicant 申請人 7

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書

Applicant 申請人 8

Personal Information 個人資料

Passport/ ID Family Name in English
身份證明文件上的英文姓氏

*

Passport/ ID Given Name in English
身份證明文件上的英文名字

*

Chinese Name
中文名字

Sex
性別

*

Passport No
護照號碼

*

HKID No.
身份證號碼

*

Date of Birth
出生日期 (DD/MM/YYYY)

*

Email
電郵

*

Residential Phone No.
住宅電話

Contact Phone No.
聯絡電話

*
You shall receive a SMS confirmation in one to two working days, if you have not received SMS confirmation, please contact us immediately.你將於一至兩個工作天內收到預約確定短訊，如未有收到訊息，請馬上聯絡我們。

HK Residential/ Postal Address
住宅/通訊地址

*

Address in UK 英國地址
Postal Code 郵政編碼
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Visa Category 簽證類別	*
IME Number/ UCI Number (If any) e.g. IME XXXXXXXX or UCI XXXXXXXX
HAP Number e.g. HAPXXXXXX	*
No. of Accompanying Children Under 11 Years of Age (if any) 共有多少位同行十一歲或以下的小童 (如有)

Health Declaration Form 健康聲明書

Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Have you done any Immigration Visa Examination before? 過去有否在其他指定醫生/本診所曾做過簽證體驗?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past? 過去有否進行過手術?	*
Any operation in the past (for Chest or Heart)? 過去有否進行過心肺手術?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of lung disease (such as tuberculosis, pneumonia or pneumothorax)? 有否關於肺部疾病 (如肺結核、肺炎或氣胸)?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Any history of family member had tuberculosis? 有沒有家庭成員曾經患有肺結核疾病?	*
Are you a known Hepatitis B/C carrier? 是否乙型/丙型肝炎帶菌者?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
Are you a known Hepatitis B carrier? 是否乙型肝炎帶菌者?	*
Any family member being a known Hepatitis B carrier or history of positive Hepatitis C tests? 有沒有家庭成員是乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Are you a known Hepatitis B carrier or having had positive Hepatitis C tests? 你是否乙型肝炎帶菌者或曾經患有陽性丙型肝炎?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you need to take long term medication, such as for Cancer, Hypertension, Diabetes or Kidney diseases? 是否需要服用長期藥物，例如：癌症、血壓、糖尿病、腎病?	*
Do you intend to apply a permanent stay in Australia in the coming 1 year? 你是否打算未來一年內申請澳洲永久居留權?	*
Are you a known Anemia/ Thalassemia? 是否有貧血或地中海貧血?	*
Will you work or study AS doctor, dentist or nurse when you arrive Australia? 在澳洲期間，你會否從事或就讀：醫生、牙醫或護士?	*
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。
(For female) First date of Last Menstrual Period (DD/MM/YYYY) (女士適用) 最近一次經期的第一天 (日/月/年)
(For female) This is to authorize UMP Medical Centre to perform Chest Xray examination on me. I am not pregnant and I understand that I shall be responsible for any possible risk which has been explained to me. (女士適用) 本人授權聯合醫務中心為本人進行肺部X光檢查。本人並沒有懷孕，並願意承擔此次檢查所引起的一切後果。

Medical Examination Consent Form 醫療體格檢查同意書


I have read, understood and agreed to the Disclaimer and Personal Data Privacy Policy. 本人已閱讀、明白及同意免責聲明及個人資料私隱政策。