1. 申請人英文全名

2. 公司名稱(英文)

3. 付款方式 (支票、銀行轉帳或入數)

4. 付款日期

5. 遞交表格日期

6. 遞交表格方式 (郵寄、WhatsApp 或電郵)

7. 電郵地址 (如適用)

8. 手機號碼 (若表格上之手機號碼與發送 WhatsApp 給我們的手機號碼不相同, 請提供全部號碼)

1. Applicant's full name

2. Company Name

3. Payment method (Cheque, bank transfer or deposit)

4. Payment date

5. Submission date

6. Submission method (by post, WhatsApp or email)

7. Email address (if applicable)

8. Mobile number (if mobile number on the form is different from WhatsApp's number, please provide both numbers to us)

(I)

(II)

(III)

(IV)

(V)

(VI)

(VII)

(VIII)

*** 請注意:

我們將不會就報名費用另發正本收據。

若閣下需要正式收據，請電郵至 receipt@health-care.com.hk 索取。(必需提供 英文全名, 公司名稱, 香港身份證英文字母及首4位數目字, 報名表格上所填寫的手提電話號碼)，我們會把電子版正式收據電郵

給您。

如需要有蓋章的紙張收據，請申請人於計劃生效後兩個月內，於下列辦公時間帶同身份證明文件正本，親身到本公司寫字樓索取 (逾期提出將不獲受理)。

寫字樓地址: 香港新界荃灣青山公路388號中染大廈28樓

寫字樓辦公時間 : 星期一至五 早上9時至下午1時 及 下午2時至6時

*** Note :

No receipts will be issued for the application fee paid.

If you need an official receipt, please send your request to receipt@health-care.com.hk (must provide full name, company name, HKID card number (first 5 alphabet(s) and digits), mobile phone

number which fills in the application form), we will send the e-receipt to you by e-mail.

If you need the paper receipt with company chop, you may pick it up in our office (Address: 28/F., CDW Building, 388 Castle Peak Road, Tsuen Wan, N.T., Hong Kong) within two months after

the start date of your dental care plan (late request will not be entertained). Please bring along the original copy of the applicant's identity document for verification of personal particulars.

Office opening hours: Monday - Friday from 9:00am-1:00pm & 2:00pm-6:00pm

我們收到申請表格後，會以電郵或WhatsApp通知申請人計劃生效日期。請提供有效電郵地址/WhatsApp號碼以便收取有關通知。

會員請依照電郵/WhatsApp上所顯示之生效日期後才致電熱線預約服務。

登記手續完成後，除申請人特別要求外，我們不會就報名費用另發正本收據***。

電郵地址請以英文正楷大寫填寫(例如: ABC@YAHOO.COM.HK) 。字體請儘量清晰，避免潦草。

Once we received the application form, we will inform the applicant for the start date of the dental care plan by e-mail or WhatsApp.

Please provide us a valid WhatsApp number and/or e-mail address (in neat and clear handwriting). Please only call for appointment booking after the start date as mentioned in the acknowlege

e-mail/WhatsApp

No official receipts will be issued for application fee paid unless requested by applicant.***

For enquiries about the status and progress of the applications, please follow below instruction and contact us via WhatsApp or email.

(i) if you apply via WhatsApp or e-mail, please contact us 14 days after submission date

(ii) if you apply by post, please contact us 18 days after submission date

(iii) if you apply via your company, please check with your HR department for the send out date, then count for 14 days after send out date & contact us for enquiry

Due to the large volume of applications received daily, please provide the following information for our easy follow up:-

表格一經遞交，將不獲退還。申請人在遞交表格前，請自行保存副本以作參考。

Application form and documents submitted would be retained by our company and will not be returned. You are advised to keep a copy for reference.

請預留十個工作天辦理登記手續 (工作天指星期一至五，公眾假期除外)

Please allow ten (10) working days for membership enrollment (The term “working days” means Monday to Friday excluding Public Holidays).

遞交前核對表

Submission Checklist

申請表格內之申請人姓名、家屬姓名、通訊地址已用英文正楷大寫填寫。

Please complete in BLOCK CAPITAL LETTERS for applicant's name, family members' name & mailing address.

所有資料已正確填妥。

All information has been properly completed.

填寫申請表格前，請先小心細閱附頁之牙科保健計劃條款及細則、備註及預約參考資料。

Before completing the application form, please read through the Terms & Conditions, Notes and Appointment Information of the attachment sheet carefully.

洗牙服務由牙齒衛生員提供。如有任何爭議，恒健牙科服務有限公司保留最終決定權。

Scaling & Polishing could be done by Dental Hygienist. Should any dispute arise, the decision of Health & Care Dental Services Limited shall be final.

如申請表格未填寫所有資料、或欠缺簽名及日期、或作出更改資料後沒有加簽確認、或填寫上不符申請資格的員工家屬資料、或付款有問題之申請將不獲處理。

The application will not be processed if : (i) The application form is not duly completed; (ii) The applicant's signature and/or signing date is left in blank;

(iii) Amendments have been made to the information in the form without being signed thereat by the applicant; (iv) with unqualified family member's information;

(v) Failed or Declined Payments

在遞交申請前，請先確定已全部填妥所有有關資料及已安排繳款，以免延誤申請。

To avoid delay in application, please make sure you have completed the form and payment is being arranged.

*** 預約熱線只提供預約服務，不會解答其他查詢。***

由於預約熱線非常繁忙，如非預約服務，請勿致電熱線。多謝合作!

WhatsApp 電話 : 646 747 02 電郵地址 : cs@health-care.com.hk

WhatsApp : 646 747 02 Email : cs@health-care.com.hk

*** Booking hotline only provide appointment booking service. ***

Since our booking hotline is very busy, for any enquiries, please contact us via WhatsApp or email.

申請牙科保健計劃之注意事項Points to note for Dental Care Plan application

由於辦理會員登記手續需時，如欲查詢報名進度，請依以下所指定的時間，透過 WhatsApp 或電郵聯絡本公司。

(i) 如經 WhatsApp 或電郵報名，請於遞交申請書14天後才聯絡我們查詢

(ii) 如經郵遞報名，請於投遞申請書18天後才聯絡我們查詢

(iii) 如經貴公司代為遞交報名表格，請先咨詢貴公司遞交表格的日期，再由該日起計14天後才聯絡我們查詢

我們每天都需要處理大量報名表格，如需查詢報名進度，請提供以下資料，方便我們更有效率跟進閣下的查詢:-

如客戶選擇以櫃員機(ATM)過數，請緊記於交易完成後取回收據，並保留此收據作為付款證明。

如客戶忘記拿取或遺失櫃員機(ATM)收據，請自行向閣下之銀行查詢補領收據之手續及所需時間銀行。銀行或會因此向閣下收取費用。

除支票付款外，本公司可接受由客戶提供真確的櫃員機(ATM)收據、櫃檯存款收據、網上銀行付款記錄、或完整之銀行月結單作為付款證明(付款證明必須清晰顯示交易金額、交易日期、完整銀行戶口號碼)。

本公司在任何情況下均不接受申請人遞交自行制作之付款記錄。

If the payment is through ATM transfer, please remember to take the receipt before you leaving the ATM Machine. Please retain it as the proof of payment.

If forgot to take or lost the ATM receipt, please check with your bank for the procedure, service lead time, and corresponding fees and charges to apply for a copy of the receipt.

We accept cheque payment, or member can provide us with the ATM Receipt, Bank Deposit Slip / Transaction Advice, e-Banking Payment Record, Bank Paper Statement as proof of payment

record (payment record must show clearly with full account number, transaction date, amount, and the status must be "Accepted"). No self-made payment record will be accepted under any

circumstances.

- 如以銀行入賬付款，存款收據之正本或影印副本均接納。

- original or photocopy of bank deposit slip

或 OR

- 如以支票付款，抬頭請寫上「恒健牙科服務有限公司」的劃線支票。 (不接受期票付款）。

- Please make a crossed cheque payable to“Health & Care Dental Services Limited". (Post-dated cheque is not acceptable).

如果以郵遞方式報名，請於投寄時支付足夠郵資。本公司不會受理任何郵資不足的郵件，亦不負責前往郵局支付欠資及收取該等郵件。

請參考香港郵政欠資郵件的處理程序:

https://www.hongkongpost.hk/tc/about_us/tips/unpaid_underpaid/index.html

如因郵資不足導致申請延誤，本公司恕不負責。

Please affix sufficient postage if enrolment forms are sent by post. The Company will not accept underpaid mails and no liability will be assumed to collect underpaid mails from the Post

Office. Please refer to below website for handling of underpaid mail by the Hongkong Post:

https://www.hongkongpost.hk/en/about_us/tips/unpaid_underpaid/index.html

We will not be responsible for any delayed applications due to insufficient postage.

申請表已填上日期和簽署(所有作出修改之地方已簽署確認)。

Application Form has been completed, signed and dated by the applicant. If amendments are made, such amendments should be signed by the applicant.

付款證明文件:-

Supporting document for payment:-

28/F., CDW Building, 388 Castle Peak Road, Tsuen Wan, New Territories, Hong Kong Tel：(852) 2666 6661

Dental Care Plan Application Form Lingnan University- Alumni Only (Co Code: LNUA)

(Membership is valid for 1 year) (Note 4)

Enrolment Period from 01/08/2018 to 31/07/2019 Submission Deadline : 15/07/2019(Note 3)

Plan K21 – HK$450

Please complete this application in English and in BLOCK letters. Name should be same as the one on your I.D. Card. This form can be copied if needed.

Name of Staff (Applicant) Membership Type Staff No. HKID No. Dental Plan

1) □ New Application / □ Renewal

K21 - $450

Please note that primary applicant must join the plan to allow his/her Family Members to enroll

Name of Family Members1 Membership Type Relationship HKID No. Dental Plan

2) □ New Application / □ Renewal

K21 - $450

3) □ New Application / □ Renewal K21 - $450

4) □ New Application / □ Renewal K21 - $450

(The applicant confirmed that he/she has joined the plan to allow his/her Family Members to enroll. All fees paid will be non-refundable). Membership fees must be paid in full, otherwise the application will not be processed.

Total Amount HK$

Application: (To avoid duplication, please do not mail and email and WhatsApp the same application)

1. By Post (Only accept cheque payment)

Please send completed application form together with crossed cheque to: Health & Care Dental Services Limited 28/F CDW Building, 388 Castle Peak Road, Tsuen Wan, New Territories. Please make cheque payable to “Health & Care Dental Services Limited”

2. Send by email (Only accept bank transfer or bank deposit)

Please bank in the total amount to HSBC Bank Account No. 509-115119-001 and send the bank deposit slip together with the completed application form by email (cs@health-care.com.hk) for processing.

3. WhatsApp (Only accept bank transfer or bank deposit)

Please bank in the total amount to HSBC Bank Account No. 509-115119-001 and send the bank deposit slip together with the completed application form by WhatsApp (please send to 646 747 02) for processing.

I f the payment is through ATM transfer, please reta in the ATM receipt as the proof of payment. . (Notes 5) We accept ATM Receipt, Bank Deposit S l ip / Transact ion Advice, e-Banking Payment Record, Bank Paper Statement as proof of payment record (payment record must show clearly with ful l account number, transact ion date, amount, and the status must be “Accepted”). No self -made payment record wil l be accepted under any circumstances.

Mailing Address

Contact Information (Mobile): (E-mail address(Notes 6) in BLOCK letters):

Notes: 1) The term “Family Members” means parents, spouse, children, siblings (“immediate family circle”) and extended family members. The term “Extended Family Member” is

defined as primary applicant's relatives outside of the immediate family circle.: for example, the primary applicant’s grandparents, aunts, uncles and cousins. The applicant confirmed that he/she has joined the plan to allow his/her Family Members to enroll. All fees paid will be non-refundable.

2) Cancellation of appointment should be done 24 hours in advance, otherwise, a surcharge of HK$50 will be charged in the next visit. Please be punctual. When member is more than 15 minutes late, appointment will be cancelled. Member need to reschedule the appointment to another day.

3) Please allow ten (10) working days for membership enrollment. (The term “working days” means Monday to Friday excluding Public Holidays). All application form (with valid payment) received after the submission deadline will not be processed. You are suggested to submit your application as early as possible.

4) I understand that the dental care plan will become effective upon successful enrolment and shall run for one year. The plan cannot be transferred and changed in the whole scheme period; the fees of dental care plan shall be paid in full and are not refundable.

5) If your payment is through ATM transfer, always take your receipt before you leaving the machine. If forgot to take or lost the ATM receipt, or no receipt provided by the ATM Machine, we can do nothing but suggest you to contact your bank directly to apply for a duplicate copy or a letter of the transaction details. You may need to pay for the bank charges for such request.

6) An automatic confirmation e-mail would be sent to your email account after successful enrolment. No official receipts will be issued for application fee paid. Please provide us a valid e-mail address in neat and clear handwriting. You may made the booking after received the confirmation email.

7) According to the Professional Code and Conduct issued by the Dental Council, no one is allowed in any way to advertise the dentist information. Applicants will only receive the dentist information once the application is accepted.

8) Health & Care Dental Services Limited reserves the right of final decision in case of any dispute arising herein. 9) The personal data of the applicants are collected for processing the application and subsequent patient record (if applicable) and Health & Care Dental Services Limited shall

observe the requirements of the Personal Data (Privacy) Ordinance (Cap. 486). 10) For further enquiries, please contact us via WhatsApp (# 646 747 02 - for text message/photos/videos only) or email (cs@health-care.com.hk).

Appointment Information:

➢ Booking Hotline: 2666 6661. This hotline only provide appointment booking service. ➢ For service other than appointment booking, please contact us via WhatsApp or email. ➢ Clinics may reserve some appointment sessions for review treatment booking, emergency booking and non-contract clients’ booking. Please allow sufficient time for

arranging an appointment in advance. ➢ Peak hours of clinics are: Monday to Friday from 5:00 pm to 8:00 pm, the whole day on Saturday ➢ Dental services are provided from Monday to Saturday only.

Signature: (Staff already read the above Notes and Appointment Information) _____________________ Date: ________________

V20171026R/CO/LNUA_(Rolling)

香港新界荃灣青山公路 388 號中染大廈 28 樓 電話：(852) 2666 6661

牙 齒 保 健 計 劃 申 請 表

嶺 南 大 學 - 校 友 專 用 (Co Code:LNUA) (一年有效期會籍) (備註 4)

報名有效日期由 01/08/2018 至 31/07/2019 截止報名日期: 15/07/2019(備註 3)

計劃 K21 – HK$450 為方便電腦操作, 請以英文正楷填寫此表格，所填姓名必須與身份證上之名字相同。如有需要，可自行影印此表格。

員工(申請人)姓名(英文正楷) 會員類別 職員編號 身份證號碼 選擇計劃

1) □ 新會員 / □ 續會會員 □ K21 - $450

申請人必須參加以上之牙齒保健計劃，其家屬方可參加並享有此優惠。

員工之家屬姓名 1 (英文正楷) 會員類別 家屬關係 身份證號碼 選擇計劃

2) □ 新會員 / □ 續會會員

□ K21 - $450

3) □ 新會員 / □ 續會會員

□ K21 - $450

4) □ 新會員 / □ 續會會員

□ K21 - $450

(申請人確認已經參加以上之牙齒保健計劃，否則家屬不可參加，而已繳付之費用將不獲退還)。如會員未有繳付全額費用，其申請將不獲處理。

合共費用 HK$

申請辦法 (3 選 1。為避免重複登記、造成混亂及延誤申請，請勿透過不同方式重複遞交報名表格，例如 :電郵後又再 WhatsApp)

1. 郵寄

(只接受支票付款)

請將填妥之申請表格連同劃線支票 (支票抬頭請註明:“恒健牙科服務有限公司”)，寄往：

新界荃灣青山公路 388 號中染大廈 28 樓，恒健牙科服務有限公司

2. 電郵

(只接受轉帳或銀行入數付款)

請將合共費用轉帳或匯入香港上海匯豐銀行戶口 509-115119-001，然後將銀行入數單據及填妥之申請表格

經電郵發送至 cs@health-care.com.hk

3. WhatsApp (只接受轉帳或銀行入數付款)

請將合共費用轉帳或匯入香港上海匯豐銀行戶口 509-115119-001，然後將銀行入數單據及填妥之申請表格經 WhatsApp

發送至 646 747 02

如客戶選擇以櫃員機 (ATM)過數，請緊記於交易完成後取回收據作為付款證明。 (備註 5)

付款證明必須經由銀行發出，並清楚顯示交易日期，入賬戶口，金額及交易狀況為接納等資料 (缺一不可 )。自行堆砌上述資料作為付款證明或未能提供付款證明的申請將不獲處理。

通訊地址 (英文)

聯絡資料 (手提電話): (電郵地址(備註 6) 請以正楷大寫填寫):

備註: 1) 上述“家屬”指申請人之 “核心家人”及“延伸家庭”成員。“核心家人” 指父母、配偶、子女、兄弟姊妹，而“延伸家庭成員”則指其他的家庭成員。申請人

確認已經參加以上之牙齒保健計劃，否則家屬不可參加，而已繳付之費用將不獲退還。

2) 取消預約必須於 24 小時前通知，否則病人須於下次應診時繳交港幣五十元之失約附加費。敬請準時出席，如遲到超過 15 分鐘，其所預約之服務將會被取消，會

員需重新預約其它時段。

3) 請預留十個工作天辦理登記手續。(工作天指星期一至五，公眾假期除外) 。任何原因導致報名表格及支票或繳費收據未能在截止報名日期前送達恒健牙科，其申請

將不獲辦理。

4) 本人明白此計劃在成功登記後，所選定之計劃於該年度內不得更改，已付之費用亦不予退還。會籍有效期為一年。所有年費和會籍皆不得轉讓。

5) 假如遺失或不能提供櫃員機收據作為付款證明，我們將不能作出任何協助，即使申請人提供賬戶號碼、入數時間、銀碼都亦沒作用！唯一方法是自行到銀行補領。

若銀行因此需要收取手續費，則費用由申請人自付。

6) 登記手續完成後，我們會以電郵形式通知申請人，而不會就報名費用另發正本收據。請提供有效電郵地址以便收取有關通知。會員收到電郵通知後可即時預約服務。

電郵地址請以英文正楷大寫填寫(例如: ABC@YAHOO.COM.HK) 。字體請儘量清晰，避免潦草。

7) 根據牙醫管理委員會之專業操守及指引，任何人士都不可將牙醫資料作任何形式之宣傳及推廣用途；故此，申請人只可於成功申請後方獲取有關資料。

8) 如有任何爭議，恒健牙科服務有限公司保留最終決定權。

9) 收集閣下之個人資料為處理閣下申請之用，恒健牙科服務有限公司將遵從《個人資料(私隱)條例》(第 486 章)之規定行事。

10) 如有查詢，可經以下途徑提出：WhatsApp (號碼 646 747 02 - 接受文字/照片/影片) 或 電郵(cs@health-care.com.hk)。

預約參考資料: ➢ 預約熱線 2666 6661。預約熱線只提供預約服務，不會解答其他查詢。 ➢ 如有其他查詢，請透過 WhatsApp 或電郵與我們聯絡。

➢ 由於各診所需預留部份時段予覆診客戶、緊急治療客戶及非合約公司客戶；為能配合各會員之首選預約時間，敬希各會員預早致電預約。

➢ 診所之繁忙時段通常為星期一至星期五下午五時至晚上八時，以及星期六整日。

➢ 牙科服務只限星期一至星期六提供。

簽 署 : (員工已仔細閱讀以上備註及預約參考資料) __________________________________ 日期：__________________

V20171026R/CO/LNUA_(Rolling)

mailto:cs@health-care.com.hk

1 | P a g e 0 8 J u n 2 0 1 8 V 1

Dental Care Plan Terms and Conditions 牙科保健計劃條款及細則 1) Dental examinations which are carried out by our General Dental Practitioners will be covered. 合約包括普通科牙科醫生之牙齒檢查。

2) Dental examinations which are carried out by our Specialists and/or Specialty Dentists will NOT be covered. 合約不包括專科醫生及/或碩士文憑醫生之牙齒檢查。

3) Small intra oral radiographs as suggested by our General Dental Practitioners will be covered by the dental plan. 合約包括我們的普通科牙科醫生建議因療程所需之口腔內 X-光細片。 CT scan (Computer tomography scan), large extra oral radiographs such as OPG (Orthopantomogram) and Lat Ceph (Lateral Cephalometric Radiograph) will NOT be covered. 合約不包括電腦掃瞄，全口 X-光片及側面頭部 X-光片。

4) Dental cleanings (Scale and polish) involving the removal of plaque and tartar deposits that have built up on the teeth over time will be covered. 洗牙服務只包括去除一般牙菌膜及牙石。 Subgingival debridement refers to the removal of the subgingival plaque and any flecks of tartar on the root surfaces subgingivally will NOT be covered. 合約不包括深層洗牙，例如(去除牙齦底下之牙菌膜及牙石)。

5) Fillings 補牙 Amalgam (black) fillings for posterior teeth (premolars and molars) due to decay will be covered. 銀粉(黑色)補牙只包括由犬齒往後之大牙(後牙)因蛀牙而引起之補牙。 Composite (white) fillings for anterior teeth (canines and incisors) due to decay will be covered. 瓷粉(白色)補牙只包括犬齒前及門牙(前牙)因蛀牙而引起之補牙。 Fillings NOT due to decay (e.g. abrasion, erosion, attrition, trauma, dislodgement, cosmetic fillings etc.) will NOT be covered. 補牙不包括非因蛀牙而引起之補牙個案 (如因為磨損、溶蝕、磨牙、創傷、補牙物料剝落及美容補牙等情況)。

6) Extractions 脫牙 Simple extractions will be covered. 合約只包括簡單脫牙。 Surgical extractions will NOT be covered. 合約不包括手術性脫牙。 Extractions of wisdom teeth (simple or surgical) will NOT be covered. 合約不包括 (簡單或手術性)之智慧齒脫牙。 Orthodontic extractions (simple or surgical) will NOT be covered. 合約不包括因矯齒治療(簡單或手術性)之脫牙。

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7) Fluoride treatment as suggested by our General Dental Practitioners and preventive advice (e.g. oral hygiene instructions, flossing instruction, diet instructions etc.) will be covered. 合約包括我們的普通科牙科醫生建議因療程所需之氟素治療及預防性建議，例如 (口腔衛生指導、使用牙線指示、飲食指導等)。

8) Emergency treatment 緊急治療 In business hour, emergency consultation and temporary dressing for pain relief will be covered. 合約包括在辨公時間內之緊急會診及臨時補牙物料。 Medications such as antibiotics and analgesics will be covered. 如有需要，合約包括抗生素及止痛藥物。 Drainage of abscess without surgery will be covered (applicable to selected plan only, please refer to the plan details). 合約包括非手術性之膿腫引流(只適用於指定計劃，詳情請參考計劃內容)。 Incisional drainage (i.e. surgical drainage) of an abscess will NOT be covered. 合約不包括手術性之切口引流。

9) Specialist treatment 專科治療 General Dental Practitioners may refer their patients to our Specialists or Specialty Dentists when the patients need a level of care that cannot be provided by them. 如有需要，普通科牙科醫生可能轉介病人至專科或碩士文憑醫生。 All consultations and treatments carried out by our Specialists and Specialty dentists will NOT be covered. 合約不包括所有專科及碩士文憑醫生之諮詢及治療。

10) Please note that the above list only consists of the excluded items related to the treatments which are covered by the Dental Plan. We can also provide a list of non-coverage items in General Dentistry by request and members are welcome to consult our dentists regarding the fees of these items prior to their treatment. 請注意，以上只提及部分合約內不包括之牙科治療，如對收費及療程有任何疑問，歡迎向我們的醫生查詢。

11) For the treatments not covered by the Dental Plan, special rates will be offered to our members. (Excluding Specialists Treatment) 會員可以以優惠收費享用合約內不包括之牙科治療 (專科治療除外)。

12) The special rates are for reference only and may vary depending on the complexity of the dental procedure. 優惠收費只供參考，實際收費會因應治療之複雜程度而更改。

13) An employee is eligible to enroll his/her dependents in our Dental Plan. 合資格員工家屬可申請相關之牙科計劃。

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14) The employee and his/her dependents may select different Dental Plans if applicable. 員工及其合資格申請之家屬可因應不同需要而各自選擇合適之牙科計劃。

15) The membership and subscription fee for a Dental Plan are not transferable. 會籍及年費不得轉讓。

16) An employee will be charged the full Dental Plan fee if he enrolls after the commencement of a contractual year. 員工無論在合約年度開始後的任何時間參加此計劃，亦須繳付全數費用。

17) No refund of the Dental Plan fee will be made if a member terminates his/her membership at any time within the contractual year. 如會員在合約年度的任何時間終止牙科計劃，已繳交之費用將不獲退還。

18) Health & Care Dental Services Ltd. reserves the right to change the clinic location and/or clinic consultation hours without notice at any time. 恒健牙科服務有限公司有權更改診所資料(例如診所地址及/或應診時間)而毋須另行通知。

19) Health and Care Dental Services Limited has the right to terminate any membership at its sole and absolute discretion in the case of dispute. 恒健牙科服務有限公司保留終止任何會員之權利。

20) Health and Care Dental Services Limited reserves the right to make the final decision on any disputes or matters relating to the Terms and Conditions of the Dental Plan. 如對此計劃的內容有任何爭議，恒健牙科服務有限公司保留最終解釋及決定權。

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Notes 備註 1) The term “Family Members” means parents, spouse, children, siblings (“immediate family circle”) and extended family members. The term “Extended Family Member” is defined as primary applicant's relatives outside of the immediate family circle. For example, the primary applicant’s grandparents, aunts, uncles and cousins. 上述“家屬”指申請人之父母、配偶、子女、兄弟姊妹(“核心家人”)及延伸家庭成員，而“延伸家庭成員”則指申請人的核心家人以外的家庭成員：例如祖父母、外祖父母、姨姑叔舅、堂表兄弟姊妹。

2) Cancellation of appointment should be done 24 hours in advance, otherwise, a surcharge of HK$50 will be charged in the next visit. Please be punctual. When member is more than 15 minutes late, appointment will be cancelled. Member need to reschedule the appointment to another day. 取消預約必須於 24 小時前通知，否則病人須於下次應診時繳交港幣五十元之失約附加費。敬請準時出席，如遲到超過 15 分鐘，其所預約之服務將會被取消，會員需重新預約其它時段。

3) Please allow ten (10) working days for membership enrollment. (The term “working days” means Monday to Friday excluding Public Holidays) 請預留十個工作天辦理登記手續。(工作天指星期一至五，公眾假期除外) 。

4) I understand that the dental care plan will become effective upon successful enrolment and shall run for one year. The plan cannot be transferred and changed in the whole scheme period; the fees of dental care plan shall be paid in full and are not refundable.. 本人明白此計劃在成功登記後，所選定之計劃於該年度內不得更改，已付之費用亦不予退還。會籍有效期為一年。所有年費和會籍皆不得轉讓。

5) If your payment is through ATM transfer, always take your receipt before you leaving the machine. If forgot to take or lost the ATM receipt, or no receipt provided by the ATM Machine, we can do nothing but suggest you to contact your bank directly to apply for a duplicate copy or a letter of the transaction details. You may need to pay for the bank charges for such request. 假如遺失或不能提供櫃員機收據作為付款證明，我們將不能作出任何協助，即使申請人提供賬戶號碼、入數時間、銀碼都亦沒作用！唯一方法是自行到銀行補領。若銀行因此需要收取手續費，則費用由申請人自付。

6) We will inform the applicant via WhatsApp or e-mail for the effective date of the dental care plan. After successful enrolment, NO official receipts will be issued for application fee paid. Official receipts will only be provided upon request. Please send the request with member’s full name, company name, first 5 digits of your HKID number, and member’s mobile number (must be the same as shown on the application form) to receipt@health-care.com.hk to get the e-receipt. Members can print out their paper receipts only when they need them. Or member can bring with identity proof (original HKID card / Passport) to our office in person for a paper receipts (please contact us before you come). Office address: 28/F., CDW Building, 388 Castle Peak Road, Tsuen Wan, N.T., Hong Kong Office working hours: Monday to Friday, from 9:00am to 1:00pm & 2:00pm to 6:00 pm 我們會經由WhatsApp 或電郵通知申請人計劃的生效日期。登記手續完成後，我們將不會就報名費用另發正本收據。若會員需要正式收據，請電郵至 receipt@health-care.com.hk 索取。(必需提供 : 英文全名、

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公司名稱、 香港身份證英文字母及首 4 位數目字、報名表格上所填寫的手提電話號碼)，我們會把電子版正式收據電郵給您。 會員可按需要自行列印紙張收據。您亦可於辦公時間內。帶同身份證明文件正本，親身到本公司寫字樓索取(會員需預先聯絡我們以作安排)。 寫字樓地址: 香港新界荃灣青山公路 388號中染大廈 28樓 寫字樓辦公時間 : 星期一至五 早上9時至下午 1時 及 下午 2 時至 6 時

7) According to the Professional Code and Conduct issued by the Dental Council, no one is allowed in any way to advertise the dentist information. Applicants will only receive the dentist information once the application is accepted. 根據牙醫管理委員會之專業操守及指引，任何人士都不可將牙醫資料作任何形式之宣傳及推廣用途；故此，申請人只可於成功申請後方獲取有關資料。

8) The personal data of the applicants are collected for processing the application and subsequent patient record (if applicable) and Health & Care Dental Services Limited shall observe the requirements of the Personal Data (Privacy) Ordinance (Cap. 486). 收集閣下之個人資料為處理閣下申請之用，恒健牙科服務有限公司將遵從《個人資料(私隱)條例》(第 486章)之規定行事。

9) For further enquiries, please contact us via WhatsApp (WhatsApp Number 646 747 02 - for text message/photos/videos only) or email (cs@health-care.com.hk). 如有查詢，可經WhatsApp 或電郵向我們提出：- WhatsApp (號碼 646 747 02 - 接受文字/照片/影片) 或 電郵(cs@health-care.com.hk)。

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Appointment Information 預約參考資料 1) Booking Hotline: 2666 6661. This hotline only provide appointment booking service. 預約熱線 2666 6661。預約熱線只提供預約服務，不會解答其他查詢。

2) For service other than appointment booking, please contact us via WhatsApp or email. 如有其他查詢，請透過 WhatsApp 或電郵與我們聯絡。 WhatsApp : 646 747 02 email 電郵 : cs@health-care.com.hk

3) Clinics may reserve some appointment sessions for review treatment booking, emergency booking and non-contract clients’booking. Please allow sufficient time for arranging an appointment in advance. 由於各診所需預留部份時段予覆診客戶、緊急治療客戶及非合約公司客戶，為能配合各會員之首選預約時間，敬希各會員預早致電預約。

4) Peak hours of clinics are: Monday to Friday from 5:00 pm to 8:00 pm, the whole day on Saturday. 診所之繁忙時段通常為星期一至星期五下午五時至晚上八時，以及星期六整日。

5) Dental services are provided from Monday to Saturday (some clinic(s) may only provide service from Monday to Friday. Please contact our booking hotline for more details). 牙科服務只限星期一至星期六提供 (個別診所只限星期一至星期五提供服務，詳情請向預約熱線職員查詢)。

預約參考資料：

Appointment Information:

不同診所之預約請致電預約熱線：2666 6661。覆診預約可於同一診所辦理。

Appointment for different clinics shall be made by appointment hotline 2666 6661. Review appointment shall be made at the same clinic.

為簡化預約程序，本公司將不發出會員咭，會員只需以身分證號碼作預約登記即可。

To simplify appointment making procedure, no membership card will be issued. Member can

simply make appointment with Identity Card Number.

取消預約必須於 24 小時前通知，否則病人須於下次應診時繳交港幣五十元之失約賠償金。

Cancellation of appointment should be done 24 hours in advance, otherwise, liquidated damages of HK$50 will be charged in the next visit.

牙科服務只限星期一至星期六提供 (個別診所只限星期一至星期五提供服務，詳情請向預約

熱線職員查詢)。

Dental services are provided from Monday to Saturday (some clinic(s) may only provide

service from Monday to Friday. Please contact booking hotline for more details).

牙科醫務所地址

Dental Clinics Location

HONG KONG 港島

Central 中環

Unit 08-10, 9/F., China Insurance Group Bldg., 141 Des Voeux Road Central, Central (Sheung Wan MTR Exit E4)

中環德輔道中 141 號中保集團大廈 9 樓 08-10 室(上環港鐵站 E4 出口)

KOWLOON 九龍 Mongkok Rm 1001-1003,10/F, Wai Fung Plaza, 664 Nathan Road, Mongkok 旺角 旺角彌敦道 664 號惠豐中心 10 樓 1001-1003 室

NEW TERRITORIES 新界

Tseung Kwan O Shop No.231-233, L2, Phase 1, Metro City, Tseung Kwan O (Po Lam MTR Exit B2) 將軍澳 將軍澳新都城一期 2 樓 231 至 233 號舖 (寶琳港鐵站 B2 出口)

Tsuen Wan Shop 116, Level 1, CDW Building (8 ½ ) , 388 Castle Peak Road, Tsuen Wan 荃灣 荃灣青山公路荃灣段 388 號中染大廈(8 咪半)1 樓 116 號鋪

Shatin Unit 1312, 13/F, Tower 1, Grand Central Plaza, Shatin 沙田 沙田新城市中央廣場一座 13 樓 1312 室

Tai Po (1) Shop 5B, Level 2, Tai Po Plaza, Tai Po 大埔 (1) 大埔大埔廣場 2 樓 5B 舖

Tai Po (2) Shop 66, Level 1, Fortune Plaza, 4 On Chee Road, Tai Po . 大埔 (2) 大埔安慈路 4 號昌運中心 1 樓 66 號舖 Tin Shui Wai Shop 228, 2/F, Phase 1, Fortune Kingswood, Tin Shui Wai

天水圍 天水圍置富嘉湖 1 期 2 樓 228 號舖

Tuen Mun Shop G72, G/F, Phase 1, Tuen Mun Town Plaza, Tuen Mun

屯門 屯門屯門市廣場 (第一期) G72 號舖

(診所地址如有更改，恕不另行通告。 Clinic location is subjected to change without prior notice.)

HEALTH & CARE DENTAL SERVICES LTD.

恒 健 牙 科 服 務 有 限 公 司 28/F., CDW Building, 388 Castle Peak Road,

Tsuen Wan, N.T., Hong Kong 香港新界荃灣青山公路 388 號中染大廈 28 樓

Tel (電話) : 2666 6661 Fax (傳真) : 2902 2558

Dental Care Plan K21

繁忙時間參考資料： Peak Time Information： ~ 診所之繁忙時段通常為星期一至星期五下午五時至晚上八時，以及星期六整日。

Peak hours of clinics are: Monday to Friday from 5:00 pm to 8:00 pm, the whole day on Saturday

~ 由於各診所需預留部份時段予覆診客戶、緊急治療客戶及非合約公司客戶；為能配合各會員之首選預約時間，敬希各會員預早致電預約。 Clinics shall reserve some appointment sessions for review treatment booking, emergency booking and non-contract

clients’ booking. Please allow sufficient time for appointment arrangement.

會員請於牙科計劃有效期屆滿前使用，逾期之牙科計劃將不會獲得延期。

Please utilize the dental scheme before expiry date; extension of the scheme after the expiration

would not be accepted.

F o r A P P O I N T M E N T, P L E A S E C A L L

牙 科 治 療 預 約 ， 請 致 電

2 6 6 6 6 6 6 1

Enquiry Centre - Monday to Friday : 9:00am – 1:00pm & 2:00pm – 6:00pm Office Hours Saturday,Sunday & P. H. : Closed

預約中心辦公時間 - 星期一至五 : 上午九時至下午一時 及 下午二時至下午六時

星期六,日及公眾假期 : 休息

(如因線路繁忙未能接聽，敬請留下口訊及聯絡資料)

(Please kindly leave your message and contact number if the hotline is busy.)

閣下所選用之牙科保健計劃 (已包括之治療項目)

Your Choice of Dental Benefit Scheme (Covered Items)

SERVICE 服 務 FREQUENCY

PER YEAR

每 年 次 數

P

LA

N K

21

1 Oral check-up & Oral Hygiene Instruction 口腔檢查及口腔衛生指導 Unlimited 次數不限

2 Intra-Oral X-Ray (when necessary) OPG X-Ray (Orthopantomogram) is excluded

口腔內 X 光細片(如有需要) 不包括全口腔 X 光(全口牙位曲

面體層片)

Unlimited 次數不限

3 Scaling & Polishing 洗牙石及牙漬 Once 一次

4 Fluoride Varnish Treatment (when necessary) 氟素治療 (如有需要) Unlimited 次數不限

5 Simple Extraction (exclude surgical extractions, extraction of wisdom teeth or extraction for orthodontic reasons)

簡單脫牙

(不包括手術性、智慧齒或因

矯齒脫牙) Unlimited 次數不限

6 Filling due to Caries – Composite Filling for Anterior Teeth

– Amalgam Filling for Posterior Teeth

因蛀牙引起之補牙

- 前牙瓷粉

- 後牙銀粉 Unlimited 次數不限

7

Emergency Treatment – Temporary Pain Relief – Temporary Filling / Dressing – Abscess (Drainage Without Surgery)

緊急治療

- 臨時止痛

- 臨時補牙 / 敷料

- 牙瘡(非手術性放膿)

Unlimited 次數不限

8 Medication for the above mentioned treatment 以上治療項目所需之藥物 Unlimited 次數不限

一切治療須由牙科醫生作最後決定 Final decision of all dental treatment shall be made by the dental practitioner.

Extra Coverage 特別項目: (Only provided in Central Clinic 只在中環診所提供)

Free consultation and examination for Oral Implant treatment.

免費”微創植齒” 治療咨詢

及檢查 Once 一次

(For details and appointment, please call 2666 6082 詳情及預約，請致電 2666 6082)

** 注意 : 1) 根據香港牙科醫生執業守則指引，病人記錄應由牙科醫生準確地記載及妥善地保存。

Attention : 而病人之 X-光片是屬於病人記錄的一部份，因此 X-光片應由牙科醫生保存。病人所

支付『照 X-光片』之費用，只屬本診所為病人提供『照 X-光片服務』之費用，並不

是該 X-光片之費用，該 X-光片應屬本診所擁有及保存。

According to the “Code of professional discipline for the Guidance of Dental

practitioners in Hong Kong”, dental practitioners should keep accurate and contemporaneous records of dental treatment. Radiographs are parts of the patient records, they shall be kept by the dental practitioners to safely maintain

these records against loss. The charge for the “X-ray radiograph” is only the service charge that we take the radiograph(s), the radiographic film(s) is legally own and kept by our clinic.

2) 有關其它牙科保健計劃條款，請參照牙科保健計劃申請表。

Other terms and conditions of your Dental Care Plan should be referred to the Dental Care Plan Application Form.

20180625

恒健牙科服務聯絡方式指南

電郵 郵寄 WhatsApp 熱線 貴公司人事部

遞交申請表格 ✓ ✓ ✓ ✗ ✗請先確定已全部填妥資料，已簽署及已安排繳款，並

自行保存副本以作參考。

遞交支票(郵寄) ✗ ✓ ✗如以支票付款，請郵寄抬頭請寫上「恒健牙科服務有

限公司」的劃線支票。 (不接受期票付款）。

遞交銀行轉帳記錄/入數紙

(WhatsApp 或 電郵)✓ ✗ ✓ ✗ ✗

請確定所提供之成功付款記錄有清楚顯示付款日期、

金額及存款帳號(香港上海匯豐銀行戶口 509-

115119-001)，否則閣下之申請將不獲處理。

本公司在任何情況下均不接受申請人遞交自行制作之

付款記錄。

查詢申請進度 ✓ ✗ ✓ ✗ ✗請提供申請人英文全名、公司名稱、付款方式、付款

日期、遞交表格日期以便跟進。

預約牙科服務 ✗ ✗ ✗ ✓ ✗

取消預約服務 ✗ ✗ ✗ ✓ ✗

更改預約日期及時間 ✗ ✗ ✗ ✓ ✗

查詢已預約的日期及時間 ✗ ✗ ✗ ✓ ✗

索取計劃內容

✓申請人需提供個人資

料，以便我們核實查

詢人之有效員工身份

✗

✓申請人需提供個人資

料，以便我們核實查

詢人之有效員工身份

✗ ✓

查詢診所地址 ✓ ✗ ✓ ✗ ✓

索取申請表格 ✗ ✗ ✗ ✗ ✓

其他 其他查詢 ✓ ✗ ✓ ✗ ✗

請提供閣下之英文全名、會員編號(如沒有會員編號，

請提供香港身份證號碼)、所查詢之事項詳情，方便我

們作出跟進。

電郵

郵寄 新界荃灣青山公路388號中染大廈28樓, 恒健牙科服務有限公司收

WhatsApp

熱線

V20171020

注意事項

由於各診所需預留部份時段予覆診客戶、緊急治療客

戶及非合約公司客戶，為能配合各會員之首選預約時

間，敬希各會員預早致電預約。

預約熱線只提供預約服務，如有其他查詢，請透過

WhatsApp 或電郵與我們聯絡。

熱門查詢閣下可直接向 貴公司人事部索取申請表格、計劃內

容、收費、診所地址等資料。

646 747 02 ( WhatsApp 不提供直接對話, 請會員以文字/照片/影片查詢 )

2666 6661

申請牙科保健服務

預約服務

cs@health-care.com.hk

聯絡方式

Health & Care Dental Services Limited Contact Information

E-Mail By Post WhatsApp HotlineClient's

HR Dept

Submission of

Application Form✓ ✓ ✓ ✗ ✗

Please make sure the application form has been completed, signed, and dated

before submission. You are advised to keep a copy of it for reference.

Submission of Cheque

(by post)✗ ✓ ✗

Please send the crossed cheque make payable to “Health & Care Dental

Services Limited” for application. (Post-dated cheque is not acceptable).

Submission of Bank

Transaction Record / ATM

Slip / Bank Deposit Slip

(by WhatsApp or E-mail)

✓ ✗ ✓ ✗ ✗

The transaction date, amount and Bank A/C Number (HSBC A/C #509-115119-

001) must shown clearly on the Bank Transaction Record. No self-made

payment record will be accepted under any circumstances.

Enquiry for the progress

of application✓ ✗ ✓ ✗ ✗

Please provide us with the applicant's full name, company name, payment

method, transaction date, application form submission date for our further

follow up.

Make appointment ✗ ✗ ✗ ✓ ✗

Cancel appointment ✗ ✗ ✗ ✓ ✗

Reschedule appointment ✗ ✗ ✗ ✓ ✗

Check for the

appointment date or time✗ ✗ ✗ ✓ ✗

Plan Details

✓Inquirer must

provide his/her

personal

information to us

for identity

verification

✗

✓Inquirer must

provide his/her

personal

information to us

for identity

verification

✗ ✓

Clinic Location ✓ ✗ ✓ ✗ ✓

Request an

Application Form✗ ✗ ✗ ✗ ✓

Others Others enquiry ✓ ✗ ✓ ✗ ✗Please provide us your full name, membership number (or HKID Number), and

the details of your enquiry for our follow up

E-mail

By Post

WhatsApp

Booking Hotline

V20171020

cs@health-care.com.hk

2666 6661

Health & Care Dental Services Limited

28/F., CDW Building, 388 Castle Peak Road, Tsuen Wan, N.T., Hong Kong

Contact Information

Notes

646 747 02 ( no voice call for WhatsApp, members please send us with text message/photos/videos for enquiry )

Application for

Dental Care Plan

Appointment

Booking

Clinics may reserve some appointment sessions for review treatment booking,

emergency booking and non-contract clients’ booking. Please allow sufficient

time for arranging an appointment in advance.

For service other than appointment booking, please contact us via WhatsApp

or email.

Top 3 enquiryApplication Form, Plan Details, Price List, Clinic Location List can be obtained

from your HR department