卫生署流行性感冒预防注射计划-CentreforHealthProtection.DOCVIP

PAGE PAGE Rev 8_2012 Rev 8_2012_web To be completed by VMO:Transaction no:_________________________Void Transaction no To be completed by VMO: Transaction no:_________________________ Void Transaction no：_________________ Residential Care Home Vaccination Programme Vaccination Consent Form Please complete the form and send to the responsible Visiting Medical Officer(s) of the residential care home for record at least ten working days before vaccination. RCH Code FORMTEXT _____________ * Please insert a “X” in the appropriate box Part A: The personal details of recipient: Name：(English) FORMTEXT , FORMTEXT (Chinese) FORMTEXT (surname) (given name) Date of Birth: FORMTEXT / FORMTEXT / FORMTEXT (dd) (mm) (yyyy) Sex:： FORMCHECKBOX Male FORMCHECKBOX Female * Identity document (Please insert a “X” in the box and fill in the information of the document used by the recipient.) Note: People aged 11 or above should fill in either Hong Kong Permanent Identity Card no. or Certificate of Exemption. FORMCHECKBOX Hong Kong Permanent Identity Card No. FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT ( FORMTEXT ) Date of Issue: FORMTEXT / FORMTEXT / FORMTEXT (dd/mm/yy) Chinese Code: FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMCHECKBOX Serial No. of the Certificate of Exemption: FORMTEXT Reference No.: FORMTEXT HKID No. shown on the Certificate: FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT ( FORMTEXT ) HKID No. shown on the Certificate: Date of Issue: FORMTEXT / FORMTEXT / FORMTEXT (dd/mm/yyyy) FORMCHECKBOX Hong Kong Birth Certificate Registration No.: FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT FORMTEXT ( FORMTEXT ) FORMCHECKBOX Hong