Corporate Customer Medical Examination Application Form

Service Type: Annual Health Check

Check-up customer information

* compulsory fields

Chinese name*
English name*
Date of Birth*
HKID No.*
(first 4 characters: A123)
Sex*
MaleFemale
Contact Phone No.*
Other Contact Person*
Other Contact Phone No.*

Appointment information

* compulsory fields

Name of Company*
Name of Service*
Items*
Additional Items
Preferred Date for Check-up*
Alternative Date for Check-up*
Preferred Time for Check-up*
Alternative Time for Check-up*
Remarks