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患者资料 Patient Information

姓名 Name * 身份证号 NRIC / FIN（完整 Full）* 电子邮箱 Email 联系电话 Mobile（用于 WhatsApp）* 出生日期 Date of Birth 性别 Gender 就诊分院 Branch 主治医师 Attending Physician * 地址 Address（请假单 / 收据用，可留空）

资料只保存在本机，用于生成本次文件；关闭页面后不会保留。若启用下方「云端同步」，生成的 PDF 与台账资料会送往你自己的 Google 帐号（Annietiang1981tcm）。完整 IC 仅用于医疗记录，依 PDPA 妥善处理。

⚙ 云端同步设置 · Cloud Sync（Google Drive + 台账 Sheet）

在 Annietiang1981tcm 帐号下部署 Apps Script 后，将网址贴在此处并启用。之后每次生成 PDF，会自动存入该帐号 Google Drive，并在「签署台账」Google Sheet 追加一行。（设定会记在本机浏览器，下次自动带出。）

Apps Script 网址 Web App URL（以 /exec 结尾）

启用云端同步 Enable

前台见证 · Witness（按分院自动列出）

前台见证 Witness

国安中医 ANNIE TIANG TCM

SINCE 1981 · TRADITIONAL CHINESE MEDICINE

日期 Date:

患者知情同意书

INFORMED CONSENT & FEE ACKNOWLEDGEMENT

姓名 Name 身份证 NRIC 电话 Tel 主治医师 Physician

一、执业资质　Professional Qualifications

本诊所所有中医师均已在新加坡中医师管理委员会（TCMPB）注册并持有有效执业证书。

All TCM physicians at this clinic are registered with the TCM Practitioners Board (TCMPB) of Singapore and hold valid practising certificates.

二、治疗性质　Nature of Treatment

本人理解针灸、推拿、理疗、拔罐、刮痧等属传统中医诊疗；医师将依患者体质与病情变化，落实「辨证论治」并实时调整用药或治疗方案。

I understand that acupuncture, Tui Na, physiotherapy, cupping and gua sha are traditional TCM treatments; physicians will implement customised "syndrome-differentiation" protocols based on individual constitution and progression.

三、医疗风险与知情权　Medical Risks & Patient's Rights

疗效因人而异，并非保证治愈。针灸可能轻微出血、瘀青或晕针；推拿理疗可能短暂酸痛。医师将在开展特定风险治疗（如微创放血等）前向患者说明。患者有权在任何阶段提问、拒绝或终止特定治疗。

Outcomes vary; cure is not guaranteed. Acupuncture may cause minor bleeding, bruising or dizziness; Tui Na/physiotherapy may cause short-term soreness. Physicians will explain specific risks (e.g. minor bloodletting) beforehand. Patients may question, refuse or terminate any therapy at any stage.

四、疗效免责与合理期望　Disclaimer & Realistic Expectations

4.1 无绝对疗效保证：依 TCMPB 执业守则，中医师不得做出根治、100% 见效或确切治愈时间之承诺。
4.2 个体差异免责：疗效取决于体质、生活习惯、病程及对医嘱的配合（按时服药、忌口等）。本诊所不承担因个人体质差异致疗效未达预期之退款要求。

4.1 Per the TCMPB Ethical Code, practitioners shall not promise a cure, 100% efficacy or a definitive recovery timeframe. 4.2 Efficacy depends on constitution, lifestyle, illness duration and compliance; the clinic is not liable for refunds due to unmet expectations arising from individual variances.

五、患者告知义务与免责　Disclosure Obligations & Exemption

5.1 真实申报：患者须如实、完整提供健康背景——如癌症、肿瘤、近期手术、心脏病、流产史、怀孕、骨质疏松、出血倾向/状况、心脏起搏器或植入物，以及既往病史、药物/食物过敏、目前服用之西药或保健品，务必先主动告知医师。
5.2 瞒报免责：若因故意隐瞒、虚报或遗漏上述关键信息，致治疗中出现任何不良反应、人身损害或后果，本诊所及执业医师概不负责。

5.1 Patients must truthfully disclose critical history (cancer, tumours, recent surgery, heart disease, miscarriage, pregnancy, osteoporosis, bleeding disorders, pacemakers/implants, allergies, current western medications/supplements) before treatment. 5.2 The clinic and its physicians are not liable for any adverse reactions, injuries or consequences resulting from intentional concealment, misrepresentation or omission.

六、个人资料保护　Personal Data (PDPA)

本人同意诊所依新加坡《个人资料保护法令》(PDPA) 及 TCMPB 保密守则，收集、使用、储存及披露本人资料，用于临床诊疗、预约提醒、随访、账务管理及法定强制通报；未经本人书面同意，绝不向第三方透露。

I consent to the clinic collecting, using, storing and disclosing my data under the Singapore PDPA and TCMPB guidelines for treatment, reminders, follow-up, billing and statutory reporting; not disclosed to third parties without my written consent.

七、收费确认　Fee Schedule（另加 9% GST）

项目 Item	收费范围 Fee Range (SGD)
问诊费 Consultation	$30 – $60
针灸（单次）Acupuncture (per session)	$150 – $239
推拿 Tui Na	$90 – $168
物理治疗 Physiotherapy	$75 – $108
药物 Medicine	$58 / $118

实际收费视医师评估之治疗内容而定，于治疗前清楚告知；以上价格另加 9% GST。Actual fees depend on the physician's assessment and are disclosed before treatment; 9% GST applies on top.

患者声明：本人确认已仔细阅读、充分理解并完全同意以上所有条款，知悉并同意上述收费，自愿接受治疗。医师/职员已向本人履行口头提示与释明义务。
Patient Declaration: I confirm I have carefully read, fully understood and absolutely agreed to all the terms above, acknowledge and agree to the fees, and voluntarily consent to treatment. The physician/staff has duly explained these terms to me.

患者签名 Patient Signature

请在此处签名 Sign here

签署日期 Date:

姓名 Name

前台见证 Witness: —

　|　机密 Confidential

需先填写姓名、电话并完成患者签名。

填写今日收费 · Enter today's charges（金额未含税，系统自动加 9% GST）

问诊费 Consultation 针灸 Acupuncture 推拿 Tui Na 物理治疗 Physiotherapy 药物 Medicine 其他 Other（金额）其他项目说明 Other – description 配套扣除 Package Deduction（未含税 −$）
当次治疗由配套支付时，填写该项未税金额付款方式 Payment（用什么付款）就诊日期 Treatment Date

配套疗程使用 · Package usage（最多 4 项 up to 4）

配套疗程 Package course	本次第几次 Session No.	共几次 Total

国安中医 ANNIE TIANG TCM

TAX INVOICE / RECEIPT

收据编号 No:

日期 Date:

今日费用收据

OFFICIAL RECEIPT

姓名 Name 身份证 NRIC 主治医师 Physician 就诊日期 Date—

项目 Item	金额 Amount (SGD)
（请于上方填写金额）

小计 Subtotal（未含税）$0.00

消费税 GST 9%$0.00

应付总额 Total Payable$0.00

付款方式 Payment—

感谢您的光临 · Thank you　|　　|　含 9% GST

配套疗程协议 · Treatment Course Agreement（金额未含 9% GST）

快速选择配套 Quick-add package（自动填入下表）

课程 Course	金额 Amount	次数 Sessions	单次 1×COD	使用人数 Used by	有效期(年) Validity	编号 Pkg No.
针灸 ACUPUNCTURE
推拿 MASSAGE
物理治疗 PHYSIO- THERAPY
其他 OTHERS

备注 NOTE 付款方式 Payment（用什么付款）收据编号 Receipt No（自动 / 可改）经手职员 Staff in charge 患者已确认理解并接受条款 Patient acknowledges & accepts the terms

国安中医 ANNIE TIANG TCM

TREATMENT COURSE AGREEMENT

日期 Date:

VER 08.06.2024

配套疗程协议书

TREATMENT COURSE AGREEMENT

NAME 姓名		NRIC/FIN
HP 电话		EMAIL

COURSE TYPE 课程	AMOUNT 金额	SESSIONS 次数	1×COD 单次	USED BY 使用人数	VALIDITY(YRS) 有效期	PKG NO. 编号
TOTAL COURSE FEE 配套总额（未含税 excl GST）						$0.00
9% GST						$0.00
TOTAL PAYABLE 应付总额（含税 incl GST）						$0.00

PAYMENT 付款方式—

NOTE 备注： —

TERMS AND CONDITIONS 条款与条件

退款与折算 Refunds & Deductions：多疗程配套属自愿购买，款项一经支付，除法律规定或诊所判定不宜继续治疗之特殊医疗原因外，原则上不予退还。若因患者自身原因申请中途退款并获诊所批准，已消费疗程不再享配套折扣，须按单次诊疗原价重新计算并扣除。
Packages are purchased voluntarily and are non-refundable in principle once paid, except as required by law or where the clinic deems the patient medically unsuitable to continue. If a mid-way refund is requested for personal reasons and approved, utilised sessions lose the package discount and are re-calculated and deducted at the standard single-session price.
取消预约 Cancellation：预约须至少提前 24 小时 更改或取消，否则自动扣除配套 1 次（退款结算时计入已消费次数）。
Appointments must be cancelled or rescheduled at least 24 hours in advance; otherwise one (1) session is automatically deducted (and counted as utilised during refund calculations).
逾期延期费 Expiry / Extension：疗程配套设有有效期；逾期后若需继续激活、使用或退款结算，须另付 $100 延期管理费。
An additional $100 fee applies if the course is activated, utilised or calculated after its expiry date.
五年作废 5-Year Forfeiture：配套自购买日起 五年内 未使用或未用完，将自动取消并完全作废，不予任何退款或补偿。
Any course not fully utilised within five (5) years from purchase is automatically cancelled and forfeited, with no refund or compensation.
医嘱免责 Medical Advice：对于忽视／不遵从本诊所医师及／或治疗师所给予之医疗建议、药物或疗法所致之后果，本诊所概不负责。
The clinic is not responsible for consequences arising from disregarding / neglecting medical advice, medication or remedies given by our physicians and/or therapists.
个人资料保护 PDPA：本人同意诊所依新加坡《个人资料保护法令》(PDPA) 及 TCMPB 保密守则收集、使用、储存及披露本人资料，用于诊疗、预约提醒、随访、账务及法定通报；未经书面同意不向第三方透露。
I consent to my data being handled under the Singapore PDPA and TCMPB guidelines for treatment, reminders, follow-up, billing and statutory reporting; not disclosed to third parties without written consent.
争议与管辖 Disputes & Governing Law：如对疗程、服务或收费有任何不满，应先与诊所管理层协商解决；本诊所保留最终决定权。本条款受新加坡共和国法律管辖。
Any grievance regarding treatment, service or fees should first be raised with clinic management; the clinic reserves the right to make final decisions. These terms are governed by the laws of the Republic of Singapore.
消费税 GST：以上所有配套金额另加 9% GST。All package amounts are subject to 9% GST.

PATIENT ACKNOWLEDGEMENT 患者确认
I acknowledge that I fully understand and accept the terms and conditions stated above (including mid-way refund re-calculations, the 24-hour cancellation policy and 9% GST). 本人确认已完全理解并接受上述所有条款与条件（包括中途退款折算、24 小时取消政策及另加 9% GST）。

PATIENT SIGNATURE 患者签名

请在此处签名 Sign here

DATE 日期

FOR OFFICIAL USE 诊所专用

RECEIPT NO 收据编号
—

DATE 日期

STAFF IN CHARGE 经手职员
—

SIGNATURE 签名

需填写姓名、电话、至少一项配套、勾选「患者确认」并完成患者签名。

填写诊断证明 · Medical diagnosis certificate（方便顾客申请意外／医疗保险理赔）

就诊日期 Date of Consultation * 受伤 / 发病日期 Date of Injury / Onset 诊断 Diagnosis * 临床发现 / 受伤经过 Clinical Findings / Cause 已行 / 建议治疗 Treatment Given 建议疗程次数 Recommended Sessions 建议休息天数 Rest Days（如适用）休息起 From（如适用）休息止 To（自动 / 可改）致 / 保险公司 · 雇主 To (Insurer / Employer) 备注 Remark

国安中医 ANNIE TIANG TCM

MEDICAL DIAGNOSIS CERTIFICATE

证明编号 No:

签发 Issued:

诊断证明书

MEDICAL DIAGNOSIS CERTIFICATE

姓名 Name 身份证 NRIC/FIN 性别 / 出生 Gender/DOB 分院 Branch

兹证明上述患者前来本诊所就诊，经注册中医师诊断如下，特此证明。
This is to certify that the above-named patient attended this clinic and was diagnosed by our registered TCM physician as follows.

就诊日期 Date of Consultation	—
受伤 / 发病日期 Date of Injury / Onset	—
诊断 Diagnosis	—
临床发现 / 受伤经过 Findings / Cause	—
已行 / 建议治疗 Treatment Given	—
建议疗程 Recommended Sessions	—
建议休息 Rest Advised	—

本证明应患者要求开具，供申请意外 / 医疗保险理赔之用。This certificate is issued at the patient's request for insurance / accident claim purposes.

主治医师 Attending Physician

国安中医注册中医师 Registered TCM Physician (TCMPB)

医师签名 / 诊所盖章 Signature / Clinic Stamp

医师签名 Physician sign here

· TCMPB Registered　|　本证明涂改无效 · Valid only without alteration

需填写就诊日期、诊断，并完成医师签名。

患者资料 Patient Information

患者知情同意书

一、执业资质 Professional Qualifications

二、治疗性质 Nature of Treatment

三、医疗风险与知情权 Medical Risks & Patient's Rights

四、疗效免责与合理期望 Disclaimer & Realistic Expectations

五、患者告知义务与免责 Disclosure Obligations & Exemption

六、个人资料保护 Personal Data (PDPA)

七、收费确认 Fee Schedule（另加 9% GST）

今日费用收据

配套疗程协议书

TERMS AND CONDITIONS 条款与条件

诊断证明书

一、执业资质　Professional Qualifications

二、治疗性质　Nature of Treatment

三、医疗风险与知情权　Medical Risks & Patient's Rights

四、疗效免责与合理期望　Disclaimer & Realistic Expectations

五、患者告知义务与免责　Disclosure Obligations & Exemption

六、个人资料保护　Personal Data (PDPA)

七、收费确认　Fee Schedule（另加 9% GST）