Patient Registration Form

Patient Registration Form v2

Personal Details


Emergency Contact

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

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?

I 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
I consent to receive clinic updates from Central Health

Insurance Payments

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 Should you have any questions about how your information is managed please send your enquiries to

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