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Clinical Intake Form

Clinical Intake Form Template for Hong Kong

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Key Requirements PROMPT example:

Clinical Intake Form

"I need a Clinical Intake Form for my new private medical clinic opening in Hong Kong in March 2025, specializing in pediatric care, which must include sections for vaccination history and parental consent, while complying with Hong Kong's healthcare regulations."

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Document background
The Clinical Intake Form serves as a crucial document in Hong Kong's healthcare system, designed to facilitate the initial assessment and documentation of patient information in medical facilities. It is typically used during a patient's first visit or when establishing a new healthcare provider relationship. The form collects comprehensive information including personal data, medical history, insurance details, and necessary consents, while ensuring compliance with Hong Kong's Personal Data (Privacy) Ordinance and healthcare regulations. This document is essential for both private and public healthcare settings, supporting continuity of care and maintaining accurate patient records in accordance with local legal requirements and medical practice standards.
Suggested Sections

1. Patient Personal Information: Basic demographic information including name, HKID/passport number, date of birth, gender, contact details, and address

2. Emergency Contact Information: Details of primary and secondary emergency contacts including relationship to patient

3. Insurance Information: Health insurance details, policy numbers, and coverage information

4. Medical History: Current medical conditions, past surgeries, chronic illnesses, and family medical history

5. Current Medications: List of current medications, dosages, and allergies

6. Primary Care Information: Details of regular doctor or healthcare providers

7. Consent and Authorization: Patient consent for treatment, information sharing, and privacy policy acknowledgment

8. Payment Information: Preferred payment method and billing information

9. Health Declaration: Current symptoms, recent travel history, and COVID-19 related questions

Optional Sections

1. Mental Health Assessment: Additional questions for mental health evaluation, used when mental health services are being sought

2. Pregnancy Information: Specific section for pregnant patients including due date, OB/GYN details, and pregnancy-related health information

3. Pediatric Information: Additional information for patients under 18, including vaccination history and developmental milestones

4. Traditional Chinese Medicine History: Section for patients seeking TCM services, including relevant history and treatments

5. Specialist Referral Information: Details of referring physician and specialty services sought

6. Language and Cultural Preferences: For patients requiring interpretation services or specific cultural considerations

Suggested Schedules

1. Schedule A - Privacy Policy: Detailed privacy policy and personal data handling procedures as per PDPO requirements

2. Schedule B - Patient Rights and Responsibilities: Comprehensive list of patient rights and responsibilities in accordance with Hong Kong Patients' Charter

3. Schedule C - Fee Schedule: Current fee structure for various services and treatments

4. Appendix 1 - Medical Records Release Authorization: Form for authorizing release of medical records to other healthcare providers

5. Appendix 2 - Special Consent Forms: Additional consent forms for specific procedures or treatments

6. Appendix 3 - Healthcare Subsidy Schemes: Information about applicable government healthcare schemes and subsidies

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

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alex.den.21@genieai.co
Relevant legal definitions
Personal Data
Medical History
Healthcare Provider
Treatment
Emergency Contact
Consent
Medical Records
Confidential Information
Insurance Provider
Pre-existing Condition
Registered Medical Practitioner
Next of Kin
Protected Health Information
Authorized Representative
HKID
Primary Care Provider
Specialist
Allergies
Chronic Condition
Medication
Privacy Policy
Medical Emergency
Traditional Chinese Medicine Practitioner
Hospital Authority
Private Healthcare Facility
Data Protection Officer
Informed Consent
Healthcare Services
Medical Information Release Authorization
Payment Terms
Relevant Industries

Healthcare

Medical Services

Mental Health

Pediatrics

Geriatric Care

Traditional Chinese Medicine

Private Clinics

Public Hospitals

Specialist Medical Centers

Allied Health Services

Relevant Teams

Reception

Patient Services

Medical Records

Compliance

Quality Assurance

Clinical Operations

Legal

Data Protection

Administrative Support

Patient Care

Relevant Roles

Medical Doctor

Nurse Practitioner

Clinic Manager

Healthcare Administrator

Medical Records Officer

Reception Coordinator

Compliance Officer

Data Protection Officer

Quality Assurance Manager

Patient Services Coordinator

Clinical Director

Practice Manager

Medical Secretary

Healthcare Legal Counsel

Industries
Personal Data (Privacy) Ordinance (Cap. 486): Governs the collection, handling, and protection of personal data, including sensitive medical information. Ensures compliance with data privacy principles and patient confidentiality.
Medical Registration Ordinance (Cap. 161): Sets standards for medical practice and practitioner registration in Hong Kong, including requirements for patient documentation and medical records.
Mental Health Ordinance (Cap. 136): Relevant for mental health assessments and consent capacity evaluation in clinical intake processes.
Hospital Authority Ordinance (Cap. 113): Establishes guidelines for public healthcare services and documentation requirements in hospital settings.
Private Healthcare Facilities Ordinance (Cap. 633): Regulates private healthcare facilities and their operational requirements, including patient intake procedures and documentation.
Code of Professional Conduct for Registered Medical Practitioners: Professional guidelines that specify requirements for patient documentation, informed consent, and confidentiality.
Patients' Charter: While not legislation, this important document outlines patients' rights and responsibilities in Hong Kong's healthcare system, affecting intake form content.
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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