MEMBERSHIP APPLICATION FOR hk-doctor.com
PERSONAL INFORMATION
Name:
User Name:
Preferred Password:
(4-8 character or numeric)
Chinese Name:
(For convenience, you may enter the telecode under your Chinese name in the ID Card)
Sector:
Qualification:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
11
12
PRACTICE INFORMATION
(if applicable)
Name of Hospital/Office:
Office Address:
(English)
Correspondence:
(English)(if different from above)
Telephone:
CONTACT INFORMATION
(for internal communication only)
Telephone:
Fax:
Email:
Pager:
Mobile:
Details will be sent to you later.