Name in English:
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Name in Chinese: | Age/Sex: |
Address:
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Telephone number: |
Place of Work/School Attended:
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Telephone number: |
Hospital(s) attended:
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Hosptial/A&E Number: |
Heavy Metal Poisoning [" "] below suspected/confirmed on : / / (dd/mm/yr)
Remarks: |
Reported by:
The personal data provided by doctors to the Department of Health (DH) will be used for the public health control of heavy metal poisoning. All data provided will be kept strictly confidential. For enquiries, please call the respective Regional Offices at:
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