知情同意书

申请人姓名证件号码根据《中华人民共和国国境卫生检疫法》及其、《外国人入境出境管理法实施细则》以及卫生部、公安部相关文件的规定，申请来华定居，或任职、就业、学习在华居留一年或一年以上的外国人包括港澳台居民和海外定居的中国公民）属于法定健康检查对象；经批准出国劳务、留学、探亲、定居及其他出境一年以上的中国公民为法定的健康检查对象；国际通行交通工具上的中国籍员工为法定的健康检查对象。您在本中心接受体检的项目包括：临床检查含内外科、五官科、放射科、心电图、超声等）、体液检查含乙型肝炎面抗原、丙型肝炎抗体、人免疫缺陷病毒抗体、梅毒螺旋抗体特异抗体、其他由质检总局、卫生行政部门根据疫情变化所要求的检测项目等）。体检结果涉及个人隐私，在收到体检报告后，请务必亲启并妥善保管。编号或条码知情同意书BJZ4047本人已阅读以上，接受上述体检项目，并支付相关费用，同时申请健康检查证明。申请人签名：日期：上海国际旅行卫生保健中心ShanghaiInternationalTravelHealthcareCenter上海国际旅行医疗保健门诊部ShanghaiInternationalTravelMedicalCenterApplicant’sFullNamePassportorIDNo.Accordingto<TheFrontierHealthAndQuarantineLawOfP.R.C.>,<SpecificRulesForEnforcingTheFrontierHealthAndQuarantineLawOfP.R.C.>,<SpecificRulesForEnforcingLawOfThePeople’sRepublicOfChinaOnControlOfTheEntryAndExitOfAliens>andrelateddocumentsissuedbytheMinistryofHealthandtheMinistryofPublicSecurityofChina,anyforeigners(IncludingHongKongandMacaoresidents,ChinesecitizensfromTaiwanProvince,Chinesemainlandcitizenssettlingoverseas)applyingtosettledown,workorstudyinChinaforoneormorethanoneyeararerequiredtoreceivehealthexamination,anyChinesecitizensapprovedtoworkin,studyin,visitorimmigrateintoanothercountryformorethanoneyeararerequiredtoreceivehealthexamination.Youaresupposedtoreceivephysicalexaminations,includingclinicalexamination(examsinmedicineandsurgery,ENT,Xray,EKGandultrasound)andbloodtests(HBsAg,antiHCV,antiHIVandtreponemalspecificantibody,anyotherstestsaccordingtooutbreakofinfectiousdiseasesrequestedbyGeneralAdministrationofQualitysupervision,InspectionandQuarantineandtheHealthMinistryofChinaetc.)orurinetests.Citingprivacyandconfidentialinformation,pleaseunsealthereportinpersonandkeepitproperlywhenyoureceivethehealthreport.BJZ4047No.orBarcodeBJZ4047ConsentFormIhavereadandunderstoodtheabovestatement.Iherebyconsenttoundergothehealthexaminationandwillpaythecost.Meanwhile，Iapplyforthecertificateofhealthexamination.Signature：Date：上海国际旅行卫生保健中心ShanghaiInternationalTravelHealthcareCenter上海国际旅行医疗保健门诊部ShanghaiInternationalTravelMedicalCenter