Registration form

Name of clinic 診所名稱* Required 須填寫

Clinic Phone 診所電話* Required 須填寫

Clinic email address 診所電子郵件* Required 須填寫

Business registration number 商業登記號碼

Scanned copy of business registration (click to upload) 商業登記之掃描副本（點擊以上載）

Clinic address 診所地址

Street address *District *HK / KLN / NT

Clinic Fax 診所傳真

Clinic Website 診所網站

Number of full-time doctors 診所內全職提供服務醫生人數

Holding company 控(持)股公司

Applicant's title 申請人稱謂

Applicant's surname 申請人姓氏

Applicant's given name(s) 申請人名字

Medical Council of Hong Kong registration number 申請人之香港醫務委員會註冊號碼

Scanned copy of said MCHK registration (click to upload) 是項香港醫務委員會註冊之掃描副本（點擊以上載）

Correspondence address 申請人聯絡地址

Street address * District *HK / KLN / NT

Email 申請人電郵地址

Office phone 申請人辦公室電話

Mobile 申請人聯絡電話

Degree / Qualification 申請人學位/資格 #1

Name of Institution #1

Year obtained #1

Degree / Qualification 申請人學位/資格 #2

Name of Institution #2

Year obtained #2

Degree / Qualification 申請人學位/資格 #3

Name of Institution #3

Year obtained #3

Is the applicant in Part 2 the official representative of your Clinic in the Federation if your membership is approved? 假若您們機構被確認為香港私營醫療機構聯會會員，第二部的申請人是否你們機構的代表？

Yes 是

No 不是

Representative's Title 代表稱謂

Representative's Surname 代表姓氏

Representative's Given Name(s) 代表名字

Medical Council of Hong Kong Registration Number 代表之香港醫務委員會註冊號碼

Scanned copy of said MCHK registration (click to upload) 代表於香港醫務委員會註冊之掃描副本（點擊以上載）

Correspondence Address 代表聯絡地址

Street Address Street Address Line 2 District

Office Phone 代表辦公室電話

Mobile 代表聯絡電話

Email 代表電郵地址

Degree / Qualification 代表學位/資格 #1

Name of Institution #R1

Year obtained #R1

Degree / Qualification 代表學位/資格 #2

Name of Institution #R2

Year obtained #R2

Degree / Qualification 代表學位/資格 #3

Name of Institution #R3

Year obtained #R3

I declare that, the above information provided on this form in support of my application is accurate and complete. 現聲明此表格內本人所填寫的資料均屬準確及詳盡．

Yes 是

Scanned copy of applicant's signature (click to upload) 申請人簽署之掃描副本（點擊以上載）

You may create an electronic signature at this website, save the image file to your computer, and upload it here. Alternatively, please scan and upload a handwritten signature. 您可以在此網站上創建電子簽名，將圖片檔案下載到您的電腦，或以人手簽名並自行掃描及存檔，然後將檔案上傳到此處。

Please confirm online payment amount. Alternatively, please make an ATM transfer or write out a cheque with the following information. 請確認網上繳費金額，你也可以進行自動櫃員機轉帳或郵寄支票，銀行戶口資料如下：

Account holder 帳戶持有人: The Federation of Private Healthcare Centres of Hong Kong Ltd
Bank name 銀行名稱: Bank of Communications
Bank account number 銀行帳號: 382537102354702
Mailing address for cheques (please quote the name of your clinic at the back of your cheque) 支票郵寄地址（請在支票背面註明您診所的名稱）: The Federation of Private Healthcare Centres of Hong Kong, 6/F, Virtus Medical Tower, 122 Queen's Road Central, Hong Kong
Email address for ATM transfer receipts (please quote the name of your clinic) 自動櫃員機轉賬收據的電郵地址（請註明您的診所名稱）: [email protected]

Payment method

Pay now with credit card 立即以信用咭付款

Pay later with other methods 稍後以其它方法付款

Please confirm credit card payment amount 請確認以下信用咭繳費金額

HK$5000.00: includes one-off registration fee ($3000) and first-year membership dues ($2000) / 港幣五千元正；包含一次性註冊費($3000)及首年會費 ($2000)

Notes 注意事項:

Applicants may be asked to provide further information/details for the consideration of the Federation Council. 申請人有可能會被要求提供更多資料以供本會之委員會作審批用途。

Membership fees: 會員費包括:

one-time registration fee of HK$3000 per member (incl. a non-refundable application processing fee of HK$500) 一次性註冊費港幣三千元正（已包含不可退回之報名手續費港幣五百元正）；
annual dues, first year, HK$2000 及每年會費港幣二千元正。

Applicants shall pay both sums by credit card during the online application process. 申請人必須於網上註冊時以信用卡同時繳交註冊費及首年會費。

Secretariat will notify shortlisted applicants individually by email after the approval of the Federation Council. 秘書處將會與成功通過本會之委員會審批的申請人作個別聯絡。

For further inquiries, please contact the Secretariat at [email protected] or +852 3893 9371. 如有查詢，請聯絡秘書處：電郵：[email protected]；電話：+852 3893 9371

paper aplication form

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