New ImMAX Club Member Registration Form

Please complete all information.
Name ： (English)
    (Chinese)
Contact No. ： (Day)
    (Night)
Fax No. ： (optional)
HKID ： - XXX (X)
Gender ：
Date of Birth ： Year Month Day
Email Address ：
Mailing Address ：
   
District ：
City/Country ： Hong Kong　 Others（Please specify: ）
Education Level ：
Occupation ： （Please specify: ）
Working district ：
Martial Status ： 　 Single　 Married
No. of kids ：
No. of elders ：
Average personal monthly income ：
Favorite offer ： （Please specify: ）
Prefer contact method ： （Please specify: ）
Concern health topic
 
 
 
 
 
 
：
 
 
 
 
 
 
Gastroenterology Liver and Gall Bladder Syndromes
Sleep Problem　 Blood Problem
Ear, Nose & Throat Problem Endocrinology
Psychological and Mood Problem Rheumatism　
Infectious Diseases Encephalopathy
Cancer Dentistry
Eye Disease Cardiovascular Diseases
Kidney Illness Skin Disease
Gynecologic Disease Bones and Joints Problem
Respiratory System Problem Diabetes
Blood Pressure Problem Headache
Short Memories Menopause
Reproductive System Problem Others （Please specify: ）
How did you hear about us ： （Please specify: ）

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