CORPORATE HEALTH CHECKUP

企業健檢預約申請 / Corporate Health Checkup Request

填寫您的資料與希望日期，讓專人協助安排適合的健檢。 / Enter your details and preferred dates. Our staff will contact you to arrange your checkup.

企業與方案 / Company & Package

企業名稱 / Company Name *請填寫所屬企業的完整名稱。 / Enter the full name of your company.

身分 / Relationship *

員工編號 / Employee ID *請填寫企業所屬員工編號。 / Please enter the employee ID assigned by your company.

預約健檢方案 / Checkup Package *請依企業提供的方案名稱填寫；不確定時可填「需專人協助」。 / Enter the package name provided by your company. If unsure, enter “Need assistance”.

自費加項（選填） / Self-paid Add-ons (Optional)加項內容與費用將由專人確認。 / Our staff will confirm the available add-ons and fees.

個人與聯絡資料 / Personal & Contact Details

真實姓名 / Full Legal Name *

身分證字號／病歷號碼 / ID or Medical Record Number *

證件上的性別 / Sex on ID Document *

出生年月日 / Date of Birth *

聯絡電話 / Contact Number *

電子郵件 / Email *

希望日期與注意事項 / Preferred Dates & Notes

首選日期 / First-choice Date *

次選日期 / Second-choice Date

備選日期 / Third-choice Date

包裹領取地址（選填） / Package Pickup Address (Optional)可先選新北市行政區，再填路名、門牌及樓層；其他縣市請直接填寫完整地址。 / Select a New Taipei district, then enter the street, number and floor. For other cities, enter the full address.

希望日期將由專人確認，送出申請不代表預約已成立。 / Preferred dates are subject to confirmation. Submitting a request does not confirm an appointment.

健康狀況與需注意事項（選填） / Health Conditions & Precautions (Optional)

其他備註 / Additional Notes

我已確認填寫內容，了解這是預約申請，實際日期需由中心確認。 / I have reviewed my details and understand that the center must confirm my appointment.填寫資料將供中心聯繫及安排本次健檢使用。 / Your details will be used to contact you and arrange this health checkup.

標示 * 為必填欄位 / * Required fields