PDF《Hospital Authority》

2 C 4. Patient'

s Consent : 病人同意 I consent to have my medical information disclosed to the applicant/concerned authority. 本人同意医院管理局将本人之病历资料发放给申请人/有关人士. Signature of the Patient 病人签署 (if patient is a minor or mentally incapable) (此栏适用於未满十八岁或因精神状况而 不能处理本身事务之病人) Date : 日期 Signature of the patient'

s parent/guardian 病人父/母/监护人签署 Signature of the Applicant 申请人签署 (Name in Block Letters) 姓名(请用正楷填写) Nature of Identity Document and Number 身份证明文件类别及号码 Date : 日期 Date : 日期 * * * * 有关申请一经接纳 有关申请一经接纳 有关申请一经接纳 有关申请一经接纳, , , ,所缴付之费用概不发还 所缴付之费用概不发还 所缴付之费用概不发还 所缴付之费用概不发还. . . . No refund of the fee paid for a medical report will be made even if the application is withdrawal before the medical report is issued. 医事报告内容只涵盖有关科目於本 医事报告内容只涵盖有关科目於本 医事报告内容只涵盖有关科目於本 医事报告内容只涵盖有关科目於本院内现存之病历 院内现存之病历 院内现存之病历 院内现存之病历. . . . Content of medical report covers the available medical record of the concerned specialty only. (回邮地址 / Mailing Address) (回邮地址 / Mailing Address) Name / 姓名: Name / 姓名: Address / 地址: Address / 地址: -

3 C Declaration 声明 声明 声明 声明 I, the Applicant, declare as follows: (Please tick the appropriate box) 本申请人现声明如下: (请在适当空格上「 」号) ( a ) I have applied for or I have been appointed by the Court as the personal representative or one of the personal representatives to administer the Deceased'

s estate. 本人已经向法庭申请或已被法庭委任为死者的唯一或其中一位遗产代理人,管理死者的遗产. ( b ) I am entitled to be the personal representative of the Deceased or I can act for and on behalf of all persons who may be entitled to apply for the administration of t........