HONG KONG DOCTORS UNION 香 港 西 醫 工 會

Hong Kong Doctors Directory Entry Form 香港醫生名冊登記表格

Please complete the form in both English and Chinese(此表格必須以英文及中文填寫)

HKDU Membership No.:       0001                   MCHK Registration No.:    M00001      

Name in English: CHAN TAI MAN 中文姓名:      陳大文          Sex 性別: Male 男 R /  Female 女 □

Quotable Qualifications (with year(s) obtained): MB BS (HK) 1987,  DCH (Ireland) 1990                                       

(For a list of quotable qualifications, please refer to http://www.mchk.org.hk/quotable.qualifications.doc)

准予引述的專業資格(請註明考取資格年份)

  香港大學內外全科醫學士 1987,  愛爾蘭皇家內科醫學院兒科文憑 1990                                                             

Clinic Address (1):診所地址(1):

(English英文):  Room 901, Hang Shing Building, 363-373 Nathan Road, Kowloon                              

(Chinese中文): 香港九龍彌敦道363-373號恆成大廈901室                                               

District 地區: Yaumatei  油麻地                        Clinic Tel. (1) 診所電話 (1): 2388 2728              

Consultation Hours:                           Day of the Week                                                                 

診症時間

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Public Holiday(s)

Time

(24-hours format)

ü

ü

ü

ü

ü

ü

   

10: 00

to

13: 00

 

ü

ü

ü

ü

ü

     

15: 00

to

18: 00

                 

:

to

:

                 

:

to

:

Range of Consultation Fees with certain number of days of basic medication (1) 診金幅度-已包若干日基本藥費 (1)

 $180 for 3 days of basic medication $180已包3日基本藥費)                                                                             

Clinic Address (2): 診所地址(2):

(English英文):                                                                                                  

(Chinese中文):                                                                                                  

District 地區:                                                   Clinic Tel. (2) 診所電話 (2):                         

Consultation Hours:                           Day of the Week

診症時間

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Public Holiday(s)

Time

(24-hours format)

               

:

to

:

                 

:

to

:

                 

:

to

:

                 

:

to

:

Range of Consultation Fees with certain number of days of basic medication (2) 診金幅度-已包若干日基本藥費 (2)

Language(s) spoken 語言:              R Cantonese 廣東話R English 英語R Mandarin (Putonghua) 普通話

     Others 其他(please specify)                                                                          

Registered Specialist in 註冊專科:                                                                 

  Nil                                                                                                                                                                                

Please put a þ to indicate in which Area of Hong Kong Doctors Directory the following particulars should be displayed

Public Area

公 眾 平 台

Members' Restricted Area

西醫工會會員專用區

Pager傳呼機:                              7777 7777           

R

R

Clinic Fax診所傳真(one only):          2385 5275     

R

R

Mobile Phone手提電話:               9999 9999      

R

E-mail Address電郵地址(one only):      hkdu@hkdu.org 

R

To be continued

Medical services available inside clinic (no more than 5 will be listed): 診所內醫療服務項目(只限五項):

(In English 英文)                                                                (In Chinese中文)

(1)  ECG                                                                    (1) 心電圖                                                      

(2)  Ultrasound                                                            (2) 超音波                                               

(3)  Physical Check Up                                       (3) 身體檢查                                             

(4)  Immunization                                                                 (4) 預防疫苗注射                                                            

(5)  Minor Operations                                                          (5) 小手術                                                            

Medical services available outside clinic (no more than 5 will be listed): 診所外醫療服務項目(只限五項):

(In English 英文)                                                                (In Chinese中文)

(1)  Home Call                                      (1) 出診                                         

(2)                                                                                      (2)                                                                                               

(3)                                                                                      (3)                                                                                    

(4)                                                                                      (4)                                                                                    

(5)                                                                                      (5)                                                                                    

Procedures and operations range of doctor's fees (optional) 診療程序及手術-可選擇註明醫生收費:

(1)  Haemorrhoid Ligation          (痔瘡結紮手術)                      Range of fees 醫生收費:  $1,000 up  (1,000元起)                                                       

(2)  Sebaceous Cyst Excision     (粉瘤切除手術)                      Range of fees 醫生收費:  $1,000 up  (1,000元起)                                                                                                

(3)  Circumcision                      (包皮環切手術)                       Range of fees 醫生收費:  $3,000                                                                                                                                 

(4)  Cervical Cancer Screening (檢查子宮頸癌)                       Range of fees 醫生收費:  $200                                                                                                         

(5)                                                                                          Range of fees 醫生收費:                                                                                              

Affiliated hospitals 使用醫院

 St. Teresa's Hospital (九龍法國醫院)                                                                             

Availability of emergency service 緊急服務            YesR                  No 沒有

Emergency contact phone number 緊急聯絡電話            9999 9999                                                         

Optional Items  自選項目

Please have              R my passport photo, and/or                     location map posted on my customized page.

[Please submit a softcopy in a PC compatible format stored in a floppy disk or CD with a total file size of not larger than 1 megabyte (mb). Otherwise a scanning fee of $50 will be required.]

You are also invited to join other free services offered by the HKDU (Information you provide below will NOT be used for the Hong Kong Doctors Directory).

1.       Display of doctor’s information in Hospitals of Hospital Authority.
R YES, I wish to display my information in Hospitals of Hospital Authority.

2.       Display of doctor’s information in Private Hospitals.
R YES, I wish to display my information in Private Hospitals.

3.       An easy-to-remember Alias Email address e.g. @hkdu.org
R YES, my preferred Alias is        chantaiman      @hkdu.org

4.       RCS-Rapid Communcation System

      R YES, I would like to subscribe to RCS, my email address is hkdu@hkdu.org     fax no: 2385 5275        

    Please check this box if you wish to opt out from the Hong Kong Doctors Directory and your name would be deleted entirely from the database of the project. If no objection received from your goodself, the appropriate information in the HKDU register will be posted on this Doctors Directory.

       若您選擇拒絕將資料刊登在香港醫生名冊內,請在格內核實,您的名字將會從資料檔案中刪除。若本會沒有收到閣下任何通知,本會便刊登您在香港西醫工會內的適當資料在香港醫生名冊上。

I certify the information given above are true and correct. 本人謹此聲明,以上內容全屬真實。

簽署                                                                                        日期

Signature:  Chan Tai Man                                       Date:         5.3.2004                             

Personal data collected will be used and processed for the purpose in provision of adequate information to the public according to guidelines of The Medical Council of Hong Kong and including those related to the work of the HKDU Enhancement of Public & Private Interface Programme only. You are at liberty to correct/update your information by contacting the HKDU Secretariat in person, via fax, mail or e-mail.

Completed Entry Form (with crossed cheque, if applicable) should be returned to the Hong Kong Doctors Union via MAIL ONLY (Room 901, Hang Shing Building, 363-373 Nathan Road, Kowloon) on or before 31st March 2004.