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免費兒童綜合眼科視光檢查
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免費兒童綜合眼科視光檢查
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參加表格
Enrolment Form
學童的年齡必須介乎二至六歲,且需在最近三個月內已經接受本中心提供的視力篩查。
Children must be aged between 2 to 6 years and have undergone vision screening provided by our center within the past three months.
學童須由家長或監護人帶到香港理工大學眼科視光學診所接受眼科檢查。
Children must be accompanied by a parent or guardian to the Hong Kong Polytechnic University Optometry Clinic for the eye examination.
在檢查過程中,眼科視光師會使用放瞳藥水,以確保能夠全面評估眼睛的健康狀況。
During the examination, optometrists will use eye drops to ensure a comprehensive assessment of eye health.
合資格學童將會由香港理工大學眼科視光學診所透過登記電話聯絡其家長。
Qualified children will be contacted by the Hong Kong Polytechnic University Optometry Clinic via registered contact phone number.
參加者如果預約後未能出席或遲到超過15分鐘,將會視為放棄此次檢查的安排。(在已預約的日期前一天或更早的情況下,最多可重新安排預約時間兩次)
Participants made an appointment but absent or register 15 minutes later than the appointment time, it will be considered a forfeiture of the arrangement for this examination. (Maximum 2 rescheduling one day or more before the appointment is allowed)
香港兒童視力篩查及教育中心保留最終決定權。
The Hong Kong Children's Vision Screening and Education Centre reserves the final decision.
Next
本人同意讓表格內填寫的學童參加香港兒童視力篩查及教育中心眼科健康檢查計劃,並同意將個人資料及學童視力篩查報告轉介給香港理工大學。I hereby consent to allow the child named in this form to participate in the Hong Kong Children's Vision Screening and Education Centre Eye Health Examination Program. I also agree to the referral of personal data and the vision screening report to The Hong Kong Polytechnic University.
*
同意 Agree
不同意 Not Agree
在檢查過程中,專業的眼科視光師會使用放瞳藥水。 During the examination, optometrists will use eye drops.
*
同意使用放瞳藥水 Agree to use eye drops
不同意使用放瞳藥水 Not Agree to use eye drops
了解更多有關放瞳藥水
Know more about the eye drops
Next
家長或監護人姓名 Parent/Guardian's Name
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稱謂 Title
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請選項
先生 Mr
小姐 Ms
女仕 Mrs
聯絡電話 Contact Number
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視力篩查報告編號 Vision Screening Report ID (如合適 If any)
學童英文姓名 Child's English Name
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First
Last
學童中文姓名 Child's Chinese Name (If any)
學童性別 Child's Gender
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男性 Male
女性 Female
學童出生日期 Child's Date of Birth
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學童於預約視力檢查時必須年齡介乎二至六歲。
Children must be aged between 2 to 6 years on eye examination appointment day.
本人同意學童於是次眼科健康檢查時,同時接受「利用智能手機作光學檢查」的研究計劃 I agree for the child to participate in the research project on " Smartphone-based photorefraction" during this eye health examination.
同意 Agree
不同意 Not Agree
了解更多「利用智能手機作光學檢查」詳情
"Smartphone-based photorefraction" Program Detail
您需要同意上述事項才能報名參加此免費兒童全面眼科檢查計劃。
Agreement to the above terms is required to register for this free comprehensive eye examination program for children.
遞交表格