香 港 特 別 行 政 區 政 府 The Government of

衞 生 署 The Hong Kong Special Administrative Region

Department of Health

香港法例第 343 章《診療所條例》

MEDICAL CLINICS ORDINANCE (CAP. 343)
診療所首次註冊申請表
APPLICATION FOR FIRST REGISTRATION OF CLINIC

填寫本表格前，請參閱第 6 及 7 頁的註冊指引。
Please refer to the Registration Guide on page 6 & 7 before completion.

# 如分項不敷填寫，申請人須另加標準的附頁(按要求提供)提供有關資料。

If there are insufficient subsections, relevant information should be provided on standard supplementary sheets (provided on request).

第一部分 診療所的資料
Section I Particulars of Clinic
(a) 診療所英文名稱：
Name of the Clinic in English

(b) 診療所中文名稱：
Name of the Clinic in Chinese

(c) 診療所英文地址：
Address of the Clinic in English

(d) 診療所中文地址：
Address of the Clinic in Chinese

(e) 電話號碼： 傳真號碼： 電郵地址：

Telephone Number Fax Number E-mail Address

(f) 診療所行將投入 服務的日期：

Tentative date of commencement of service

日 月 年
Date Month Year

(g) 診療所每日開放時間 (請詳述)：

Daily opening hours of the Clinic (please provide details)

(h) 診療所每星期診症日數：
Number of days of operation of the Clinic in every week

(i) 診 金： 藥物費用／日數：
Consultation Fee Drugs Charge／Number of days

過去一年內有否更改診金：
Any changes in consultation fee last year: (No)

其他：
Others
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 (j) 診療所收入的運用：
Use of income from the Clinic

(k) 服務的範疇：
Scope of service

第二部分 組織的資料
Section II Particulars of the Organization

(a) 組織英文名稱：
Name of the Organization in English

(b) 組織中文名稱：
Name of the Organization in Chinese

(c) 組織英文地址：
Address of the Organization in English

(d) 組織中文地址：
Address of the Organization in Chinese

(e) 電話號碼： 傳真號碼：

Telephone Number Fax Number

(f) 診療所宗旨：
Objects of the Clinic

(g) 組織獲授權人
Authorized person of the Organization

姓名：______________________________________________ (中文) (Chinese)

Name: Mr ________________________________________________________ (英文) (English)

職位：_______________________________________________________________________________ (中文) (Chinese)

Position:______________________________________________________________________________ (英文) (English)

電話號碼：_________________ 傳真號碼：_________________ 電郵地址：_________________________________

Telephone Number Fax Number E-mail Address

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第三(甲)部分 診療所醫務負責人的資料
Section III (A) Particulars of Medical in-charge of the Clinic

(a) 醫務負責人姓名： (英文) (中文)

Name of Medical in-charge English Chinese

(b) (HKID Card Number):

(c) 香港醫務委員會之註冊編號： 薪 金：
Registration Number in Medical Council of Hong Kong Salary

(d) 通訊地址：
Correspondence Address

(e) 電話號碼： (手提) (辦公室) 傳真號碼：

Telephone Number Mobile Office Fax Number

第三(乙)部分 診療所其他註冊醫生的資料 (如適用) #

Section III (B) Particulars of other Registered Medical Practitioners of the Clinic (if applicable) #

(1) 註冊醫生姓名： (英文) (中文)

Name of registered medical practitioner English Chinese

(HKID Card Number):

香港醫務委員會之註冊編號： 薪 金：
Registration Number in Medical Council of Hong Kong Salary
(2) 註冊醫生姓名： (英文) (中文)
Name of registered medical practitioner English Chinese
(HKID Card Number):

香港醫務委員會之註冊編號： 薪 金：
Registration Number in Medical Council of Hong Kong Salary
(3) 註冊醫生姓名： (英文) (中文)
Name of registered medical practitioner English Chinese
(HKID Card Number):

香港醫務委員會之註冊編號： 薪 金：
Registration Number in Medical Council of Hong Kong Salary

第三(丙)部分 其他受僱職員的資料 (如適用) #

Section III (C) Particulars of Other Employees (if applicable) #

(a) 其他僱員總人數：
Total Number of other employees

(b) (1) 僱員姓名： (英文) (中文)

Name of employee English Chinese

於診療所的職位：
Position in the Clinic

專業資格或已完成之相關訓練課程：
Professional qualification(s) or relevant training course(s) completed

於診療所的聘任日期：
Date of employment in the Clinic

受僱於診療所的薪金詳情：
Remuneration details of employment in the Clinic

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 (2) 僱員姓名： (英文) (中文)
Name of employee English Chinese

於診療所的職位：
Position in the Clinic

專業資格或已完成之相關訓練課程：
Professional qualification(s) or relevant training course(s) completed

於診療所的聘任日期：
Date of employment in the Clinic

受僱於診療所的薪金詳情：
Remuneration details of employment in the Clinic

(3) 僱員姓名： (英文) (中文)

Name of employee English Chinese

於診療所的職位：
Position in the Clinic

專業資格或已完成之相關訓練課程：
Professional qualification(s) or relevant training course(s) completed

於診療所的聘任日期：
Date of employment in the Clinic

受僱於診療所的薪金詳情：
Remuneration details of employment in the Clinic

(4) 僱員姓名： (英文) (中文)

Name of employee English Chinese

於診療所的職位：
Position in the Clinic

專業資格或已完成之相關訓練課程：
Professional qualification(s) or relevant training course(s) completed

於診療所的聘任日期：
Date of employment in the Clinic

受僱於診療所的薪金詳情：
Remuneration details of employment in the Clinic

(5) 僱員姓名： (英文) (中文)

Name of employee English Chinese

於診療所的職位：
Position in the Clinic

專業資格或已完成之相關訓練課程：
Professional qualification(s) or relevant training course(s) completed

於診療所的聘任日期：
Date of employment in the Clinic

受僱於診療所的薪金詳情：
Remuneration details of employment in the Clinic

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第四部分 申請人聲明
Section IV Declaration of Applicant
本人謹此聲明：
I declare that:
據本人所知，本表格內所填報的資料均屬真確無訛。
The information provided in this application form is true and correct to the best of my knowledge.

本人已閱讀及同意於表格內之「個人資料私隱聲明」 。
I have read and agreed with the “Personal Data Privacy Statement”

姓名
Name

職位
Position

簽署
Signature

組織獲授權人簽署
Signature of authorized person of the Organization

組織印鑑 (如適用)
Organization chop (if applicable)

日期 :
Date

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 註冊指引
Registration Guide

(a) 申請人必須填妥第一、第二、第三(甲)及第四部分。 如適用，亦須填妥第三(乙)及(丙))部分。

Applicant must complete Sections I, II, III(A) and IV. If applicable, Section III(B) and (C) must also be
completed.

(b) 申請人須向診療所註冊主任申請註冊(經辦人 : 私營醫療機構規管辦公室) ，並把申請遞交到下列地

址：－
The applicant should submit the application form to Registrar of Clinics (Attn.: Office for Regulation of
Private Healthcare Facilities) at the following address: -

香港灣仔愛群道 32 號
愛群商業大廈 6 樓
診療所註冊主任
(經辦人 : 私營醫療機構規管辦公室)
(查詢電話：3107 8451)
Registrar of Clinics
Department of Health
(Attn.: Office for Regulation of Private Healthcare Facilities)
6/F, Guardian House
32 Oi Kwan Road
Wan Chai, Hong Kong
(Enquiry Number： 3107 8451)

(c) 申請人須將下列文件連同申請表一併提交：
The applicant should submit the following documents together with the application form:
(1) 由香港醫務委員會簽發之最新周年執業證明書副本 (包括醫務負責人及其他註冊醫生)
A photocopy of the latest Annual Practising Certificate issued by the Medical Council of Hong Kong
(including Medical in-charge and other registered medical practitioners)
(2) 醫務負責人及其他註冊醫生的聲明書(正本)〈附件 I〉
Declaration of Medical in-charge and other registered medical practitioners (Original)〈Annex I〉
(3) 診療所收入之運用聲明書 (正本) 〈附件 II〉
Declaration on the Use of Income Derived from the Clinic (Original) 〈Annex II〉
(4) 商業登記申請書的副本或由稅務局局長發出的商業登記證的影印本
A photocopy of the Business Registration Application or the Business Registration Certificate from the
Commissioner of Inland Revenue
(5) 社團註冊證書影印本
A photocopy of the Certificate of Society Registration
(6) 公司註冊處處長發出的公司註冊證書的影印本
A photocopy of the Certificate of Incorporation issued by the Registrar of Companies
(7) 組織大綱及章程一份，內容顯示社團／註冊公司屬不攤分盈利組織
A copy of memorandum and articles of association of the organization to show that it is not profit
sharing in nature
(8) 包括以下詳情之診療所圖則：
Lay-out plan of the clinic showing among other details the following
(i) 房間數目、面積及用途
Number and size of rooms and their purpose
(ii) 衞生設備及廁所的位置
Location of sanitary fittings and latrines

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 (d) 申請人必須於預期開業前最少一個月遞交診療所之註冊申請。遞交申請後，申請人應通知本署安排處
所之實地視察。於所有申請所須之文件已遞交，及申請所涉及之處所、設備及人手已準備妥當時，本
署方會進行實地視察。經最後一次實地視察確認符合有關之要求後，本署將會於十四個工作天內簽發
註冊證書。
Application for registration as a clinic must be made not later than 1 month before the intended date for
commencement of service. After the submission of application, the applicant should inform the Department
to arrange for on-site inspection of the premises. On-site inspection would only be conducted after all
required documents have been submitted, and when the premises, equipment and staffing to which the
application relates are ready for operation. Upon confirmation of compliance with the relevant
requirements at the last on-site inspection, the Certificate of Registration will be issued within 14 working
days.

(e) 根據第 343 章第 5 條診療所註冊主任可就，但不限於下列情況拒絕註冊診療所：

In accordance with Section 5 of Cap. 343, the Registrar of Clinics may refuse to register a clinic if under but
not limited to the following circumstances:
(i) 得自或將會得自開設或經營診療所的收入，並非或將不會純粹運用於貫徹該診療所的宗旨；或
the income derived or to be derived from the establishment or operation of the clinic is not, or
will not be, applied solely towards the promotion of the objects of the clinic; or
(ii) 除真誠地用以支付任何正式受僱的註冊醫生，依據第 8 條所批予的豁免而僱用的人以及在該診
療所工作的護士及傭工的酬金外，該等收入的任何部分現時或將會直接或間接以分紅、獎金或
其他分發利潤的方式支付予或轉讓予申請人本人、如此正式受僱的任何人或任何其他人。
any portion of such income, except payment in good faith of remuneration to any such properly
employed registered medical practitioners, persons employed pursuant to an exemption granted under
section 8, nurses and menial servants working in the clinic, is, or will be, paid or transferred directly or
indirectly by way of dividend, bonus or otherwise howsoever by way of profit to the applicant himself,
or to any persons properly so employed, or to any other persons howsoever.

(f) 組織包括社團、機構及公司。
Organization includes society, institution and company／incorporation.

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 (附件 I)
(Annex I)
醫務負責人或醫生的聲明書
Declaration of medical-in-charge or medical practitioner

本人有意申請成為

診所的

I wish to apply to be a medical-in-charge of

Clinic.

本人聲明
I declare that

(a) 本人 在香港或其他地方被裁定犯有任何可判處監禁的罪行。 (註 1)
I have not been convicted in Hong Kong or elsewhere of any offence punishable with
imprisonment. (Note 1)

(b) 本人 受到香港醫務委員會的紀律處分。 (註 1)
I have not been subject to disciplinary action by the Medical Council of Hong
Kong. (Note 1)

簽署：
Signature
姓名：
Name
電話號碼：
Telephone number
日期：
Date

註 1： 如是肯定的答覆，請於另頁提供定罪或紀律處分的詳情。
Note 1: If the answer is affirmative, please provide details of the conviction or Disciplinary
action in a separate sheet.

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 (附件 II)
(Annex II)
診療所收入之運用聲明書
Declaration on the Use of Income Derived from the Clinic

本人聲明：
I declare that
(i) 得自或將會得自開設或經營名為
的診療所之收入，現時及將會純粹運用於貫徹該診療所的宗旨；
the income derived or to be derived from the establishment or operation of the clinic
known as
is, and will be, applied solely towards the promotion of the objectives of the clinics;

及
and

(ii) 除真誠地用以支付任何正式受僱的註冊醫生、依據《診療所條例》(第 343 章)第 8 條所批

予的豁免而僱用的人以及在該診療所工作的護士及傭工的酬金外，該等收入的任何部分現
時及將來均不會直接或間接以分紅、獎金或其他分發利潤的方式支付予或轉讓予申請人、
如此正式受僱的任何人或任何其他人。
any portion of such income, except payment in good faith of remuneration to any such
properly employed registered medical practitioners, persons employed pursuant to an
exemption granted under section 8 of the Medical Clinics Ordinance (Cap. 343), nurses
and menial servants working in the clinic, is not, and will not be, paid or transferred
directly or indirectly by way of dividend, bonus or otherwise howsoever by way of profit
to the applicant, or to any persons properly so employed, or to any other persons
howsoever.

及
and

(iii) 就專為會員及會員家屬服務的註冊職工會所經營的診療所而言，凡得自或將會得自開設或
經營該診療所的收入，在扣除第(i)及(ii)段許可用途的支出後，現時及將會純粹運用於獲《職
工會條例》(第 332 章)第 33(1)(f)條授權的用途，而其運用的方式不會使該等收入的任何部
分支付予任何受僱於該診療所的人，或使該等人得益。
in the case of a clinic run by a registered trade union exclusively for its members and the
families of such members, the income derived or to be derived from the establishment or
operation of the clinic and remaining after expenditure for the purposes permitted in
paragraphs (i) and (ii) is and will be applied solely for the purposes authorized in section
33(1)(f) of the Trade Unions Ordinance (Cap. 332) and so applied in such a manner that
no part thereof shall be paid to or for the benefit of any person employed in such clinic.

組織之名稱及印鑑：
Name and Chop of the Organization

組織獲授權人： 簽署：
Authorized Person of the Organization Signature
姓名：
Name
電話號碼：
Telephone Number
日期：
Date
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 收 集 個 人 資 料 聲 明
Personal Information Collection Statement
收集資料的目的
Purpose of Collection
1. 當衞生署向申請人提供服務及進行其他有關活動時，申請人所提供的個人資料，會由衞生署作以下用途：
The personal data are provided by applicants with whom the Department of Health (DH) interacts in the delivery of services,
and other related activities. The personal data provided will be used by DH for the following purposes:
(a) 處理首次註冊為診療所的申請，重新註冊的申請及獲得豁免受第 7 條規限之診療所的豁免續期申請
Processing the applications for first registration; re-registration of clinics; renewal of exemption from Section 7
(b) 紀錄
Recording
(c) 統計
Preparing statistics
(d) 於法律程序上作參考
Using as reference in legal proceedings.
根據《診療所條例(第 343 章)》
，提供個人資料是強制的。
The provision of personal data is obligatory under the Medical Clinics Ordinance, Cap. 343.
接受轉介人的類別
Classes of Transferees
2. 所提供的個人資料，主要由本署內部使用，但亦可能於有所需要時，因以上第 1 段所列目的向其他政府部門或有關
人士披露。 此外，資料只可於你同意作出該種披露或作出該種披露是《個人資料(私隱)條例》所允許的情況下，才
向有關方面披露。
The personal data you provided are mainly for use within DH but they may also be disclosed to other Government bureaux
／departments or relevant parties for the purposes mentioned in paragraph 1 above, if required. Apart from this, the data
may only be disclosed to parties where you have given consent to such disclosure or where such disclosure is allowed under
the Personal Data (Privacy) Ordinance.
查閱個人資料
Access to Personal Data
3. 根據《個人資料(私隱)條例》第 18 條及 22 條以及附表 1 第 6 原則所述，你有權查閱及修正個人資料，包括有權取得
你於以上第 1 段所述情況下所提供的個人資料。 應查閱資料要求而提供資料時，可能要徵收費用。
You have the right of access and correction with respect to your personal data as provided for in Sections 18 and 22 and
Principle 6 of Schedule 1 of the Personal Data (Privacy) Ordinance. Your right of access includes the right to obtain a copy
of your personal data. A fee may be imposed for complying with a data access request.
查詢
Enquires
4. 有關所提供個人資料(包括查閱及修正資料)的查詢，應送交：
Enquiries concerning personal data provided, including the making of access and corrections, should be addressed to:

香港太古城太古灣道 14 號
4 樓 402 室
私營醫療機構規管辦公室
高級行政主任(私營醫療機構)
電話號碼： 3107 8451
Senior Executive Officer (Private Healthcare Facilities)
Office for Regulation of Private Healthcare Facilities
Room 402, 4/F
14 Taikoo Wan Road
Taikoo Shing, Hong Kong
(Enquiry Number： 3107 8451)

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