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Individual Membership Enrollment Form

For more information or for groups, please contact vivian.di@parkwayhealth.cn.
 
To purchase a ParkwayHealth Membership Plan, please complete this form and leave it with our billing staff or fax it to 6279 7698 (Shanghai Centre Medical and Dental Centers), 6242 8678 (Hong Qiao Medical Center),6385 9890 (Specialty and Inpatient Center), or 5032 5826 (Jin Qiao Medical and Dental Center), or 6375 5688 (Shanghai Gleneagles International Medical & Surgical Center).

Membership Plan Desired: Membership Fee Per Person: (RMB)
Total Number of Members: Total Membership Fee: (RMB)

If you have both an English name and a Chinese name, please list below the name that you will use when you check into any of our centers so that we can create your patient chart properly (please use Pinyin for Chinese names).

Family Name First Name Middle Name Birthday MM / DD / YY Nationality Gender Membership # (Internal use)
, M F
, M F
, M F
, M F
Shanghai Address: Postal Code:
Company Name: Fax :
Office Phone: Home Phone:
E-mail address:  
Insurance Company: Evacuation Company:

PAYMENT METHOD
Please note that memberships become effective upon receipt of payment.
  • For cash payment, please pay to any of our centers .
  • For credit card payment, please also fax a copy of your credit card front and back. Please make sure the credit card is registered in your name, with your signature and is valid for at least three months.
  • A 50 RMB Membership Card replacement fee may be applied per lost card.
Cash Visa MasterCard American Express Diners Club JCB
Total Amount:   Today's Date:
ParkwayHealth Staff Initials:   Paid:


FOR FAXED APPLICANTS:
I authorize the following amount to be charged to my account:
Card Number:   Expiration Date:
Name (Please print clearly):
Signature:   Date:

Corporate Membership (optional)
You may wish to consider a corporate membership, which will provide you with a dedicated account manager to handle customer service issues and account renewals, on-site group vaccinations and group discounts for health screening and other services. We would be happy to contact your company to discuss membership; please provide the contact information here:
Name:   Phone:   Fax:
   
 
   
   
   
 
     
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