Staff职员Spouse.PDF

User Guide for Health Screening Program 體格檢查指引 Please bring along this “User Guide” to the clinic for identification. 請擕同本「體格檢查指引」往診所作証明之用。 Note : Please tick the appropriate box. 註: 請在適當的空格內填上 號 Name of Company: Staff Association of The Chinese University of Hong Kong (Vio code: CUSA 01) 公司客戶名稱 Teacher’s Association of The Chinese University of Hong Kong (Vio code: CUTA 01) Name of Examinee: HKID./Passport No.: 受檢查者名稱 身份証/護照號碼 Name of related Staff: HKID./Passport No.: 有關職員姓名 身份証/護照號碼 Relationship with Staff 與職員之關係: Staff 職員 Spouse 職員配偶 Children 職員子女 Plan A Plan B Plan C Plan D Plan E Recommended for Recommended for Recommended for Recommended for Recommended for aged below 50 over 50 (Male) over 50 (Female) aged over 60 (Male) aged over 60 (Female) 建議 50 歲以下人士 建議 50 歲以上 (男士) 建議 50 歲以上 (女士) 建議 60 歲以上 (男士) 建議 60 歲以上 (女士) MEX V439 MEX V440 MEX V444 MEX V441 MEX V442 $700 per exam/每次 $1200 per exam/每次 $1045 per exam/每次 $1300 per exam/每次 $1150 per exam/每次 Cash / Credit Card Cash / Credit Card Cash / Credit Card Cash / Credit Card Cash / Credit Card 現金 / 信用咭 現金 / 信用咭 現金 / 信用咭 現金 / 信用咭 現金 / 信用咭 Chosen Clinic 選擇診所: Central 中環 / TST 尖沙咀 / Tsuen