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    中文姓名 Chinese Name

    英文姓名 English Name

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    性別 Gender

    出生日期 Date of Birth

    年齡 Age

    體重 Weight in KG

    電郵 Email

    手提電話 Mobile Number

    住宅電話 Land Line

    地址 Address

    你是素食者嗎?Are you vegetarian?

    是 Yes否 No

    病史 History of Disease

    敏感 Do you have any allergies?

    緊急聯絡人 Emergency Contact Person

    緊急聯絡號碼 Emergency Contact Phone

    如何知道我們?How did you find us?

    朋友 Friends傳單 Leaflet網絡 Internet報章雜誌 Newspaper/Magazine電郵 E-Mail醫生 Doctor其他 Other

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