Appointment *First Name *Last Name *Sex MaleFemale Date of Birth *Nationality Address Zip - Telephone Number Country code - Fax Country code - *Email (ex : aaa@gmail.com ) Passport Number Language ChineseEnglishOthers(specify) Have you been to ChengChing General Hospital？ YesNo If yes,CCH Registration Number Preferred Date ofAppointment Reason for Appointment Past Medical History DiabetesKidney diseaseDepressionThyroid problemsOthers(specify) *Message for us *Captcha Captcha code if there is a problem, please click on the image to refresh Note: ＊Please bring any medication that you are currently taking so that the doctor can have a complete understanding of your medical needs.