All information given by me to Gleneagles Healthcare Wong Chuk Hang, Hong Kong (“the Clinic”) and Gleneagles Hospital Hong Kong (“the Hospital”) is true and correct to the best of my knowledge;
本人提供予港怡醫療(黃竹坑)（診所）及 港怡醫院（醫院）的所有資料，在本人的個人認知範圍內，皆屬實和正確;

I agree to pay charges for all goods and services rendered to me by the Clinic;
本人同意支付所有由診所提供予本人的物品和服務的規定費用;

I agree to pay any outstanding charges that have not been paid or covered by my insurer;
本人同意支付所有尚未繳付或保險公司未能承保之額外費用;

I hereby authorise the Clinic and the Hospital to contact and release/disclose/share all my personal data (including but not limited to medical record) to/with my insurer, its agent or broker for activities pertaining to my insurance claim, or any accreditation institutions/organisations/company involved in accreditation of the Clinic and the Hospital;
本人在此授權診所及醫院就本人的保險索償事宜與本人的承保人或其附屬之仲介人或經紀人聯繫，及向其提交/披露/分享或索取所有與本人有關的個人資料（包括但不限於醫療紀錄），及授權診所及醫院提交/披露/分享所有與本人有關的個人資料予參與評審醫院的任何認可機構/組織/公司;

I give my consent herein to the Clinic and the Hospital to send its direct marketing and health promotion materials in relation to its services to me by post, SMS, electronic mail, telephone calls or other means of communication via my contact information provided by me to the Clinic and the Hospital.
本人同意診所及醫院可以藉郵件、短訊、圖文傳真、電子郵件或其他形式的傳訊或通過電話通話，向本人提供與健康服務或健康訊息有關的資料。

I give my consent herein to the Clinic and the Hospital to send its Patient Feedback Form to me by electronic mail or other means of communication; via my contact information provided by me to the Clinic for service quality improvement. If you do not agree to give your consent, please contact Gleneagles Healthcare Wong Chuk Hang, Hong Kong.
本人同意診所及醫院以電子郵件或其他方式，向本人發送意見回鐀問卷，以供診所作檢討服務質素用途。如閣下不願意接受本協議，請與港怡醫療 (黃竹坑) 聯絡。

I give my consent herein to the Clinic and the Hospital to send my medical records or information including Signs and Symptoms; Test results to my attending doctor via SMS, electric mail, telephone calls or other forms of communication.
本人同意診所及醫院以電郵或其他方式，將本人之醫療資訊包括病徵及試檢結果發放給主診醫生。

I confirm that I understand and agree with the contents of the Gleneagles Healthcare Wong Chuk Hang, Hong Kong’s Privacy Policy Statement which is available at https://www.gleneagles-healthcare.com.hk/privacy-policy-statement or Clinic counter. I consent to the Clinic and the Hospital using the personal data provided in this form for the purposes as stated in the Gleneagles Healthcare Wong Chuk Hang’s Privacy Policy Statement.
本人確認已明白及同意港怡醫療(黃竹坑)在網站 https://www.gleneagles-healthcare.com.hk/zh-hk/privacy-policy-statement 或登記處所提供的私隱政策聲明。本人在此授權診所及醫院跟據港怡醫療(黃竹坑)的私隱政策聲明，使用本人在表格內所提供的個人資料。