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預約日期 Preferred Date
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你從何得知MY PLACE的資訊？How did you know about MY PLACE?
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「關懷愛滋」網站 AIDS Concern's Website
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姓名 Name
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電話 Phone
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性別 Sex
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男 Male
女 Female
其他 （可於備註註明）Other（Please specify in Remarks）
電郵 Email
*
預約日期 Preferred Date
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DD
1
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MM
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YYYY
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1921
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尿道炎測試 Urethritis Test
口腔拭子測試 Oral Swab Test
生殖器拭子測試 Genital Swab Test
肛門拭子測試 Anal Swab Test
HPV 33型 DNA檢測 HPV 33 Geno type DNA Test
口腔拭子測試 Oral Swab Test
生殖器拭子測試 Genital Swab Test
肛門拭子測試 Anal Swab Test
HSV 1&2 檢測 HSV 1&2 Test
口腔拭子測試 Oral Swab Test
生殖器拭子測試 Genital Swab Test
肛門拭子測試 Anal Swab Test
請問您從何得知MY PLACE的資訊？ How did you know about MY PLACE?
*
關懷愛滋網站 AIDS Concern‘s Website
社交平台 Social Media Sites
搜尋引擎 (如 Google ,Yahoo!) Search Engines (eg Google ,Yahoo!)
他人介紹 Referred by Others
其他 （可於備註註明）Other（Please specify in Remarks）
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姓名 Name
*
電話 Phone
*
性別 Sex
*
男 Male
女 Female
其他 Others
電郵 Email
*
擬體檢日期 Preferred Date (星期日休息 Closed on Sundays)
*
DD
1
2
3
4
5
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/
MM
1
2
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5
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8
9
10
11
12
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
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2002
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1999
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1991
1990
1989
1988
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1982
1981
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1978
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1974
1973
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1971
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1969
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1963
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1952
1951
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1948
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1941
1940
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1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
你從何得知MY PLACE的資訊？How did you know about MY PLACE?
*
「關懷愛滋」網站 AIDS Concern's Website
社交平台 Social Media Sites
搜尋引擎(如Google,Yahoo) Search Engines (eg Google, Yahoo)
他人介紹 Referred by Others
其他(可於備註註明) Others (please specify in Remarks)
備註 Remarks
提交 Submit
Please enable JavaScript in your browser to complete this form.
姓名 Name
*
電話 Phone
*
性別 Sex
*
男 Male
女 Female
其他 Others
電郵 Email
*
擬預約日期 Preferred Date (星期日休息 Closed on Sundays)
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29
30
31
/
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1953
1952
1951
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1928
1927
1926
1925
1924
1923
1922
1921
1920
希望預約的體檢計劃 Checkup Package Preferred
*
體檢套餐 Checkup (Plan A)
體檢套餐 Checkup (Plan B)
體檢套餐 Checkup (Plan C)
體檢套餐 Checkup (Plan D)
自選套餐 "Just Check" Plan
獨立化驗項目 Individual Test
你從何得知MY PLACE的資訊？How did you know about MY PLACE?
*
「關懷愛滋」網站 AIDS Concern's Website
社交平台 Social Media Sites
搜尋引擎(如Google,Yahoo) Search Engines (eg Google, Yahoo)
他人介紹 Referred by Others
其他(可於備註註明) Others (please specify in Remarks)
備註 Remarks
提交 Submit
Please enable JavaScript in your browser to complete this form.
姓名 Name
*
電話 Phone
*
使用者 Client
*
現有使用者 I'm on PrEP
新使用者 I'm not currently on PrEP
電郵 Email
*
預約日期 Preferred Date 逢星期日休息 (Closed on Sundays)
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
你從何得知MY PLACE的資訊？How did you know about MY PLACE?
*
「關懷愛滋」網站 AIDS Concern’s Website
社交平台 Social Media Sites
訂房app廣告 Ads on Room Booking Apps
搜尋引擎(如Google,Yahoo) Search Engines (eg Google, Yahoo)
他人介紹 Referred by Others
其他(可於備註註明) Others (please specify in Remarks)
備註 Remark
提交 Submit
