登记表
                             Registration Form

姓Surname  ____________________________________________________________

名First Name_________________________________________________________

性别Sex______________________________________________________________    照片

生日Date of Birth____________________________________________________

身份证ID_____________________________________________________________

地址Address_____________________________________________________________________

城市/邮编City/Zip Code____________________________________________________________________

国家Country________________________________________________________________________________

电话/手机Telephone/Cell___________________________________________________________________

传真Fax____________________________________________________________________________________

护照号码Passport No________________________________________________________________________

申请签证的领事馆Embassy for Visa Application______________________________________________

职位Profession_____________________________________________________________________________

信用卡类型Credit Card Type________________________________________________________________

信用卡号码Credit Card Member Account No___________________________________________________

信用卡有效期Credit Card Valid Date________________________________________________________

适合治疗的日期Preferred date for treatment________________________________________________

住宿要求（在选择框内打√）

Room required( please, would you kindly specify your choice with a cross) 

□ Double room 双人间
□ Single room 单人间

Payment付费方式

□ cash 现金
□ bank transfer银行转帐
□ credit card信用卡

日期Date签名Signature __________________________________________________________

Please, would you kindly fill in the questionnaire overleaf. Thank you!

烦请您完整填写此函，谢谢！