Electronic Health Record Programme

Online Enrolment Form

Online submission is completed and account activation is available after 1 hour. Please activate your account
in-person at any one of the prescribed Healthcare Providers, using the Hong Kong Smart Identity Card as
authentication means. If no activation was made within 12 months after the online submission, the related
information will be deleted accordingly.

Application Detail
Application date and time:

06-01-2015 15:12

(DD-MM-YYYY HH:MM)
Transaction Reference number:

OES-060115-1-00005

Part A: Basic information

HKIC No.:

A123***(3)

English Name:

chu, kokw

Other Name:

sd

Chinese Name:
Date of Birth(DD-MM-YYYY):

01-01-1990

Sex:

Female

Part B: Communication Information and Means

Home Phone:
Office Phone:
Mobile Phone:

852-98774444

Other Phone:
Communication Means:

SMS

SMS Phone No.:

852-98774444

Email:
Language for Communication:

Chinese

Agree to receive notification whenever

Yes

eHealth Record has been accessed:

Correspondence Address:

FLAT 1, FLOOR 2, BLOCK 3,

ER,
ER,
New Territories, Tuen Mun District,
Hong Kong

Residential Address:

FLAT 1, FLOOR 2, BLOCK 3,

ER,
ER,
New Territories, Tuen Mun District,
Hong Kong