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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*

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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*

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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*

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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*

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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*

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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*

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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*

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

Note: Please provide address in English
註︰必需用英文填寫

*

Address in UK 英國地址 Note: No UK address available, please write N/A 註︰如沒有英國地址請填上 N/A	*
Postal Code 郵政編碼	*
Nationality 國籍	*
Visa Category 簽證類別	*
Visa Category 簽證類別	1007 1096 1201 *
Have you received medical examination document from IRCC? 是否收到領事館驗身信?	*
If you have not received medical examination document from IRCC, please select your visa category: 如還未有領事館驗身信，請選擇簽證類別：	*
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以下的小童 (如有)

Health Declaration Form 健康聲明書

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

I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of UK. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到英國領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Australia. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到澳洲領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of New Zealand. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到紐西蘭領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Canada. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到加拿大領事館。 I hereby authorize UMP medical Centre to give full particulars of the results of this medical examination, including prior medical history to the Consulate General of Japan. 現授權聯合醫務中心將本人之詳細體格檢查報告結果, 包括過往病歷紀錄, 呈交到日本領事館。	*
(For 15 years old above applicant only) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (只適用於15歲以上之申請人) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。 (If applicable) I do give consent to UMP Medical Centre to conduct blood test for HIV antibodies. (如適用) 本人同意在聯合醫務中心進行愛滋病血液抗體測試。
I understand that as requested by Consulate General of Canada for my vaccination history handling has no impact to my visa application. 本人明白加拿大領事館要求疫苗接種紀錄的處理，對本人簽證申請不會有任何影響。	*
I acknowledge that UMP Medical Centre provides a nurse to accompany me throughout the examination by a doctor, and I confirm that: 本人已經知道與醫生會面時, 聯合醫務中心會提供護士陪伴, 本人確認:	*


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。