Personal Information Collection Statement

Personal Information Collection Statement

  1. The information collected in this form will be used for the application and liaison in the activities of the School of Optometry, The Hong Kong Polytechnic University. All such information will be destroyed after use.
  2. If you need to check or change your personal information after submitting this form, please contact the Optometry Clinic via email:
  3. The personal data collected in this form can be owned, transferred and used for audit, liaison, administration and planning purposes by the School of Optometry, The Hong Kong Polytechnic University.



  1. 此表格所收集的資料將用作處理參與香港理工大學眼科視光學院活動的申請及聯絡之用,此等資料將於無需保留時全部銷毀。
  1. 如在遞交此表格後要查閱或更改個人資料,請透過電郵致 聯絡眼科視光學診所。
  1. 此表格所收集的個人資料,均可由香港理工大學眼科視光學院持有、轉告及用於審核、聯絡、行政及策劃之用途。

I have read and agreed to the content of the above personal data collection statement. / 本人已閱讀及同意上述個人資料收集聲明的內容。

Patient information 應診者資料

Name 姓名 / Patient Name 應診者姓名

(Must be identical to the information on HKID card or Passport 必須與身份證或護照資料相同)

Date of Birth 出生日期

Format: dd-mm-yyyy

Contact person 聯絡人

Contact no. 聯絡電話

Email Address 電郵地址