HKMA Community Network

Reply Form

To: The HKMA Secretariat

Please fax (at 2865 0943) or mail the completed form to the HKMA Secretariat

Personal Particulars

Name : (English) ______(Chinese) ______

Contact Tel No : ______Fax No : ______

Mailing Address : ______

______

Email : ______

Type of Practice : ______Specialty: ______

District of HKMA Community Network You Preferred

HONG KONG / q Central & Western / q Eastern / q Wanchai / q Southern
KOWLOON / q Kowloon City / q Kwun Tong / q Shamshuipo / q Wong Tai Sin
q Yau Tsim Mong / q Sai Kung
NT / q Kwai Tsing / q NT North / q Shatin / q Tai Po
q Tsuen Wan / q Tuen Mun / q Yuen Long
Island / q Island

Areas of Interest

q  One-School-One-Doctor Scheme

(Name of School Assigned in the Last Academic Year: ______)

q  One-Institution-One-Doctor Scheme

q  Health Education Activities

q  Media Enquiries

q  Public Services

q  Regional Welfare Programme in respective Districts

To encourage better cooperation with the community, please state below the time slot(s) you would be available for health activities:

Weekdays

Morning : ______a.m. - ______a.m. (Mon/Tue/Wed/Thu/Fri)

Afternoon : ______p.m. - ______p.m. (Mon/Tue/Wed/Thu/Fri)

Saturday

Morning : ______a.m. - ______a.m.

Afternoon : ______p.m. - ______p.m.

Sunday

Morning : ______a.m. - ______a.m.

Afternoon : ______p.m. - ______p.m.

Recommendation/ Feedback

______

Date: ______Signature: ______

All Members Are Welcome to the HKMA Community Network.