香港大學「笑容無界限」幼兒蛀牙治療計劃
HKU Dentistry "SmilesForAll" Early Childhood Caries Treatment Project
English name of the child (same as HKID) 幼兒英文姓名（與身份證相同）
Date of birth 出生日期
Age of applicant 申請人年齡
Gender 性別
M 男
F 女
English name of parent/legal guardian (same as HKID) 家長或合法監護人英文姓名（與身份證相同）
Relationship with applicant 與申請人之關係
Contact number 家長或合法監護人電話
Email address 家長或合法監護人電郵地址
請確認申請人已準備以下資料（只接受圖片檔）：
Please confirm that the applicant has prepared the following documents (image only):
Copy of Hong Kong birth certificate of applicant (or other legal documents proving the identity as legal guardian) 申請人之香港出世紙副本（或其他法律文件以證明合法監護人之身份）
Choose File 選擇文件
Copy of HKID of applicant's parent/legal guardian 家長或合法監護人之香港身份證副本
Choose File 選擇文件
Valid proof of address (within 3 months) (e.g. utility bills, bank letters) 三個月內發出之有效住址證明（如水電媒帳單、銀行信等）
Choose File 選擇文件
(1) Proof of CSSA; or (2) Public housing tenancy 相關政府部門發出的 (1) 綜援紙副本 或 (2) 公屋租約副本
Choose File 選擇文件
請如實填寫以下選項：
Please declare the following facts truthfully:
Applicant is willing to comply with the entire treatment plan and schedule. 申請人願意完成整個治療方案並配合治療時間安排。
Yes 是
No 否
Applicant is medically fit to receive dental treatment, including minor surgeries. 申請人健康狀況允許接受牙科治療，包括小型口腔手術。
Yes 是
No 否
Applicant has read through and understands the "Statement of Collection of Personal Information". 申請人已仔細閱讀並了解本診所之「收集求診者個人資料聲明」。(https://shorturl.at/glhzv)
Yes 是
No 否
Applicant is between 1-5 years old and suffering from caries. 申請人年齡介乎1至5歲並需接受蛀牙治療。
Yes 是
No 否
Submit Application 遞交申請
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