Cheng Ching Hospital

First Name

Last Name

Sex

Male　Female

Date of Birth

Nationality

Address

Zip　 -　

Telephone Number

Country code　 -　

Fax

Country code　 -　

Email

(ex : aaa@gmail.com )

Passport Number

Language

Chinese　 English
Others(specify)

Have you been to Changhua
Christian Hospital？

Yes　No

If yes,
CCH Registration Number

Preferred Date of
Appointment

Reason for Appointment

Past Medical History

Diabetes Kidney disease　 Depression Thyroid problems
Others (specify)

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