{"id":10571,"date":"2023-03-29T15:48:30","date_gmt":"2023-03-29T07:48:30","guid":{"rendered":"https:\/\/www.centralhealth.com.hk\/patient-registration-form\/"},"modified":"2025-09-13T18:17:28","modified_gmt":"2025-09-13T10:17:28","slug":"%e5%b0%b1%e8%a8%ba%e7%99%bb%e8%a8%98%e8%a1%a8","status":"publish","type":"page","link":"https:\/\/www.centralhealth.com.hk\/zh-hant\/%e5%b0%b1%e8%a8%ba%e7%99%bb%e8%a8%98%e8%a1%a8\/","title":{"rendered":"\u5c31\u8a3a\u767b\u8a18\u8868"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"10571\" class=\"elementor elementor-10571\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0f0f81a e-flex e-con-boxed e-con e-parent\" data-id=\"0f0f81a\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-aea9622 elementor-widget elementor-widget-heading\" data-id=\"aea9622\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Patient Registration Form<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-88d17fa elementor-widget elementor-widget-formidable\" data-id=\"88d17fa\" data-element_type=\"widget\" data-widget_type=\"formidable.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"frm_forms  with_frm_style frm_center_submit frm_style_formidable-style\" id=\"frm_form_15_container\" data-token=\"fd53e52d74962ae31415f246d417128d\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_patient-registration2\" data-token=\"fd53e52d74962ae31415f246d417128d\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Patient Registration Form v2<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"15\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_15\" id=\"frm_hide_fields_15\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"patient-registration2\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_15\" name=\"frm_submit_entry_15\" value=\"1e369e82a4\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/zh-hant\/wp-json\/wp\/v2\/pages\/10571\" \/><input type=\"hidden\" name=\"item_meta[123]\" id=\"field_kahx93\" value=\"\" data-frmval=\"\"\/>\n<div id=\"frm_field_124_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Personal Details<\/h3>\r\n\r\n\r\n<div id=\"frm_field_125_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_t2o8m2\" id=\"field_t2o8m2_label\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_t2o8m2\" name=\"item_meta[125]\" value=\"\"  data-sectionid=\"124\"  data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_126_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_mhbxq2\" id=\"field_mhbxq2_label\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_mhbxq2\" name=\"item_meta[126]\" value=\"\"  data-sectionid=\"124\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_127_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm12 frm_first frm_fourth\">\r\n    <label for=\"field_7kfq42\" id=\"field_7kfq42_label\" class=\"frm_primary_label\">Date of Birth\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_7kfq42\" name=\"item_meta[127]\" value=\"\"  data-sectionid=\"124\"  maxlength=\"10\" data-reqmsg=\"Date of Birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_128_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm4 frm4 frm_fourth vertical_radio\">\r\n    <div  id=\"field_ljdhq2_label\" class=\"frm_primary_label\">Gender\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ljdhq2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_128-0\">\t\t\t<label  for=\"field_ljdhq2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[128]\" id=\"field_ljdhq2-0\" value=\"Male\"\n\t\t   data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Male<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_128-1\">\t\t\t<label  for=\"field_ljdhq2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[128]\" id=\"field_ljdhq2-1\" value=\"Female\"\n\t\t   data-reqmsg=\"Gender cannot be blank.\" data-invmsg=\"Gender is invalid\" aria-invalid=\"false\"  \/> Female<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_129_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_half\">\r\n    <label for=\"field_e4nbm2\" id=\"field_e4nbm2_label\" class=\"frm_primary_label\">HKID \/ Passport Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_e4nbm2\" name=\"item_meta[129]\" value=\"\"  data-reqmsg=\"HKID \/ Passport Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_130_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_iizxu32\" id=\"field_iizxu32_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_iizxu32\" name=\"item_meta[130]\" value=\"\"  data-sectionid=\"124\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_131_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_siy032\" id=\"field_siy032_label\" class=\"frm_primary_label\">Mobile Tel\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_siy032\" name=\"item_meta[131]\" value=\"\"  data-sectionid=\"124\"  data-reqmsg=\"Mobile Tel cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_132_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_k7d8x2\" id=\"field_k7d8x2_label\" class=\"frm_primary_label\">Mailing Address\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[132]\" id=\"field_k7d8x2\" rows=\"2\"  data-sectionid=\"124\"  data-reqmsg=\"Mailing Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Paragraph is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_134_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Emergency Contact<\/h3>\r\n\r\n\r\n<\/div>\r\n\r\n<style>\r\n#frm_field_36_container span:after {\r\n    content: \" (Please insert parents \/ guardian's email if age is under 16)\";\r\n    color: #555;\r\n    font-size: 13px;\r\n}\r\n<\/style>\n<div id=\"frm_field_135_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm4 frm_first\">\r\n    <label for=\"field_ssdbg2\" id=\"field_ssdbg2_label\" class=\"frm_primary_label\">Name (Contact 1)\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ssdbg2\" name=\"item_meta[135]\" value=\"\"  data-sectionid=\"134\"  data-reqmsg=\"Name (Contact 1) cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_136_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm4\">\r\n    <label for=\"field_8jofq2\" id=\"field_8jofq2_label\" class=\"frm_primary_label\">Relationship\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_8jofq2\" name=\"item_meta[136]\" value=\"\"  data-sectionid=\"134\"  data-reqmsg=\"Relationship cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_137_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm4 frm4\">\r\n    <label for=\"field_49ulg2\" id=\"field_49ulg2_label\" class=\"frm_primary_label\">Mobile Tel\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_49ulg2\" name=\"item_meta[137]\" value=\"\"  data-sectionid=\"134\"  data-reqmsg=\"Mobile Tel cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_138_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm12 frm_first\">\r\n    <label for=\"field_ragfs2\" id=\"field_ragfs2_label\" class=\"frm_primary_label\">Name (Contact 2)\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ragfs2\" name=\"item_meta[138]\" value=\"\"  data-sectionid=\"134\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_139_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm4\">\r\n    <label for=\"field_eseip2\" id=\"field_eseip2_label\" class=\"frm_primary_label\">Relationship\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_eseip2\" name=\"item_meta[139]\" value=\"\"  data-sectionid=\"134\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_140_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm4\">\r\n    <label for=\"field_51lur2\" id=\"field_51lur2_label\" class=\"frm_primary_label\">Mobile Tel\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_51lur2\" name=\"item_meta[140]\" value=\"\"  data-sectionid=\"134\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_142_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Consent to receive medical information by E-mail<\/h3>\r\n\r\n\r\n<div id=\"frm_field_143_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first vertical_radio\">\r\n    <div  id=\"field_b5l2n2_label\" class=\"frm_primary_label\">\u2022 I consent to receive test results and information relating to my medical care by E-mail<br\/>\u2022 I understand internet communications cannot be guaranteed to be secure or error free\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_b5l2n2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_143-142-0\">\t\t\t<label  for=\"field_b5l2n2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[143]\" id=\"field_b5l2n2-0\" value=\"Yes\"\n\t\t   data-sectionid=\"142\"  data-reqmsg=\"\u2022 I consent to receive test results and information relating to my medical care by E-mail&lt;br\/&gt;\u2022 I understand internet communications cannot be guaranteed to be secure or error free cannot be blank.\" data-invmsg=\"\u2022 I consent to receive test results and information relating to my medical care by E-mail&lt;br\/&gt;\u2022 I understand internet communications cannot be guaranteed to be secure or error free is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_143-142-1\">\t\t\t<label  for=\"field_b5l2n2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[143]\" id=\"field_b5l2n2-1\" value=\"No\"\n\t\t   data-sectionid=\"142\"  data-reqmsg=\"\u2022 I consent to receive test results and information relating to my medical care by E-mail&lt;br\/&gt;\u2022 I understand internet communications cannot be guaranteed to be secure or error free cannot be blank.\" data-invmsg=\"\u2022 I consent to receive test results and information relating to my medical care by E-mail&lt;br\/&gt;\u2022 I understand internet communications cannot be guaranteed to be secure or error free is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_145_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Consent for our clinics to receive a copy of your previous medical records<\/h3>\r\n\r\n\r\n<div id=\"frm_field_163_container\" class=\"frm_form_field  frm_html_container form-field\">\n<p style=\"font-weight: bold; font-weight: 15px; color: #3f4b5b\">\nOn 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?\n<\/p>\n<\/div>\n<div id=\"frm_field_147_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_family-doctors\" id=\"field_family-doctors_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_family-doctors\" name=\"item_meta[147]\" value=\"\"  data-sectionid=\"145\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_148_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first vertical_radio\">\r\n    <div  id=\"field_r6ir42_label\" class=\"frm_primary_label\"><strong style=\"text-decoration: underline\">Consent<\/strong><br\/>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\u2019s care\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_r6ir42_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_148-145-0\">\t\t\t<label  for=\"field_r6ir42-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[148]\" id=\"field_r6ir42-0\" value=\"Yes\"\n\t\t   data-sectionid=\"145\"  data-reqmsg=\"&lt;strong style=&quot;text-decoration: underline&quot;&gt;Consent&lt;\/strong&gt;&lt;br\/&gt;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\u2019s care cannot be blank.\" data-invmsg=\"&lt;strong style=&quot;text-decoration: underline&quot;&gt;Consent&lt;\/strong&gt;&lt;br\/&gt;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\u2019s care is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_148-145-1\">\t\t\t<label  for=\"field_r6ir42-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[148]\" id=\"field_r6ir42-1\" value=\"No\"\n\t\t   data-sectionid=\"145\"  data-reqmsg=\"&lt;strong style=&quot;text-decoration: underline&quot;&gt;Consent&lt;\/strong&gt;&lt;br\/&gt;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\u2019s care cannot be blank.\" data-invmsg=\"&lt;strong style=&quot;text-decoration: underline&quot;&gt;Consent&lt;\/strong&gt;&lt;br\/&gt;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\u2019s care is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_149_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first vertical_radio\">\r\n    <div  id=\"field_x23ht2_label\" class=\"frm_primary_label\">I consent to receive clinic updates from Central Health\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_x23ht2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_149-145-0\">\t\t\t<label  for=\"field_x23ht2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[149]\" id=\"field_x23ht2-0\" value=\"Yes\"\n\t\t   data-sectionid=\"145\"  data-reqmsg=\"I consent to receive clinic updates from Central Health cannot be blank.\" data-invmsg=\"I consent to receive clinic updates from Central Health is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_149-145-1\">\t\t\t<label  for=\"field_x23ht2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[149]\" id=\"field_x23ht2-1\" value=\"No\"\n\t\t   data-sectionid=\"145\"  data-reqmsg=\"I consent to receive clinic updates from Central Health cannot be blank.\" data-invmsg=\"I consent to receive clinic updates from Central Health is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_206_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first vertical_radio\">\r\n    <div  id=\"field_h07c0_label\" class=\"frm_primary_label\">I consent for Central Health (Hong Kong) to share\/receive my medical records with Central Health London (UK).\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_h07c0_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_206-145-0\">\t\t\t<label  for=\"field_h07c0-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[206]\" id=\"field_h07c0-0\" value=\"Yes\"\n\t\t   data-sectionid=\"145\"  data-reqmsg=\"I consent for Central Health (Hong Kong) to share\/receive my medical records with Central Health London (UK). cannot be blank.\" data-invmsg=\"I consent for Central Health (Hong Kong) to share\/receive my medical records with Central Health London (UK). is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_206-145-1\">\t\t\t<label  for=\"field_h07c0-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[206]\" id=\"field_h07c0-1\" value=\"No\"\n\t\t   data-sectionid=\"145\"  data-reqmsg=\"I consent for Central Health (Hong Kong) to share\/receive my medical records with Central Health London (UK). cannot be blank.\" data-invmsg=\"I consent for Central Health (Hong Kong) to share\/receive my medical records with Central Health London (UK). is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_154_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Insurance Payments<\/h3>\r\n\r\n\r\n<div id=\"frm_field_161_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_insur_1_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_insur_1_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_161-154-0\">\t\t\t<label  for=\"field_insur_1-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[161][]\" id=\"field_insur_1-0\" value=\"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.\"  data-sectionid=\"154\"  data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"This field is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> 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.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_162_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_insur_2_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_insur_2_label\" role=\"group\" style=\"font-weight: bold\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_162-154-0\">\t\t\t<label  for=\"field_insur_2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[162][]\" id=\"field_insur_2-0\" value=\"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.\"  data-sectionid=\"154\"  data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"This field is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> 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.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_151_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_6rss62\" id=\"field_6rss62_label\" class=\"frm_primary_label\">Signature\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad151' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#BFC3C8;--bg-color:#ffffff;--active:#579AF6;--inactive:#eaeaea;--active-text:#ffffff;--inactive-text:#3f4b5b;--button-margin:27px;--button-size:16px;--button-padding:8px;--button-side-margin:27px;--icon:20px\">\n\n\t\t<ul class=\"sigNav frm_hidden \">\n\t\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"frm_icon_font frm_signature_icon\" aria-hidden><\/i><\/a><\/li>\n\t\t\t\t<li class=\"typeIt\"><a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\"><i class=\"frm_icon_font frm_keyboard_icon\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[151][typed]\" class=\"name\" id=\"field_6rss62\" autocomplete=\"off\" value=\"\"  style=\"width:400px\" maxlength=\"150\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"151\" data-fieldname=\"item_meta[151]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[151][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_152_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div style=\"text-align: center;\"><strong>Privacy Statement<\/strong><\/div>\n<p>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.<br \/>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<\/p>\n<\/div>\n<div id=\"frm_field_153_container\" class=\"frm_form_field  frm_html_container form-field mi-reset-btn\"><a href=\"#\" onclick=\"document.getElementById('form_patient-registration').reset();\">Reset<\/a><\/div>\n<div id=\"frm_field_164_container\" class=\"frm_form_field form-field \">\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Register<\/button>\r\n\r\n\r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<input name=\"frm_state\" type=\"hidden\" value=\"EmsaCKcN5lfVdbttOwOyE44swiaKOEvVuBV1kLDWTNb2f2OLaO+EJxVkGIVfYH1E\" \/><style>\r\n.frm_forms form {\r\n  padding-left: 17px;\r\n  padding-right: 17px;\r\n}\r\n.frm_forms input[type=\"email\"], .frm_forms input[type=\"password\"] {\r\n  font-size: 16px;\r\n    background-color: transparent;\r\n    box-shadow: none;\r\n}\r\n}\r\n.frm_forms input[type=\"email\"]::placeholder , .frm_forms input[type=\"password\"]::placeholder {\r\n   color: #6E6E6E !important;\r\n}\r\n\r\n.frm_submit button {\r\n  padding: 14px 78px 14px 78px !important;\r\n  font-weight: bold !important;\r\n}\r\n\r\n.frm_forms  fieldset {\r\n  padding-bottom: 0 !important;\r\n}\r\n\r\n.mi-reset-btn a {\r\n    font-size: 15px;\r\n    font-weight: bold;\r\n    color: white;\r\n}\r\n\r\n.mi-reset-btn {\r\n    background: #ce1f25;\r\n    border: 1px solid #cc3619;\r\n    border-radius: 10px;\r\n    margin-left: auto;\r\n    margin-right: auto;\r\n    padding-top: 14px;\r\n    padding-bottom: 14px;\r\n    min-width: 220px;\r\n    text-align: center;\r\n}\r\n\r\nlabel#field_family-doctors_label {\r\n    display: none;\r\n}\r\n\r\n#field_family-doctors {\r\n    width: 300px;\r\n}\r\n\r\ndiv.frm_form_field.form-field.frm_top_container:has(#field_family-doctors):before {\r\n    content: 'Family doctors \/ GP\/ specialists: ';\r\n    font-size: 15px;\r\n    color: #3f4b5b !important;\r\n    font-weight: bold !important;\r\n}\r\n\r\n#field_insur_1_label, #field_insur_2_label {\r\n    float: left !important;\r\n    width: 20px !important;\r\n}\r\n\r\ndiv[aria-labelledby=\"field_insur_1_label\"], div[aria-labelledby=\"field_insur_2_label\"] {\r\n    width: calc(100% - 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