GOBS-013-R1-02/18 Page 1 of 1

Hosp No. : HKID No.:

Case No. :

Name :

DOB : M / F

Adm Date :

Contact No. : Obstetrics Booking Form

*GOBS-01

3-R1-0

2/18

*

Please FAX to GHK Labour Ward. Fax no.: 3903-3412 Tel no.: 3153-9277

Doctor Name / Code Name: ________________________ Code: _______________

Doctor’s Clinic Contact Number Clinic Tel no.: ________________________________________

Mother Particulars Name: ___________________________________________

*HK Permanent Resident / HK Resident

Travel Document Type :

HKID Passport Two-way permit

Travel Document No.: ______________________________

Travel Document Expiry Date: ________________________

Husband Particulars Name: ___________________________________________

*HK Permanent Resident / HK Resident

Travel Document Type:

HKID Passport Two-way permit

Travel Document No.: ______________________________

Last Menstruated Date (LMP)

DD/MM/YY: _________________________________________

Expected Date of Confinement (EDC) DD/MM/YY: _____________ (By Date) ___________ (By USG)

1st Exam at Doctor’s Clinic/ GHK DD/MM/YY: _________________________________________

One Month after EDC DD/MM/YY: _____________ (By Date) ___________ (By USG)

No. of Fetus *Singleton / Multiple

*Cross out the inappropriate alternative.

Official Use Only

OBS Booking Reference Number

____________________________________________________

Doctor’s Signature: _________________________

Obstetrics Packages 產科套餐

Others Additional Charges 其他特別收費

Admission deposit入院按金

HK$20,000 HK$25,000 HK$30,000 HK$45,000

HK$19,800 HK$26,800 HK$33,800 HK$42,800

HK$25,800

HK$6,800

HK$12,000

HK$1,120

HK$32,300

HK$8,000

HK$16,000

HK$1,580

HK$48,300

HK$9,000

HK$22,000

HK$1,580

HK$5,000

HK$6,800

HK$900

HK$62,300

HK$12,300

HK$28,000

HK$1,580

Standard標準房

Semi-Private Single

半私家單人房

Private Single私家房

Family Suite家庭套房

Normal Vaginal Delivery Package (3 Days and 2 Nights)

自然分娩計劃 (三日兩夜)

Elective Caesarean Section Package(5 Days and 4 Nights)

剖腹分娩計劃 (五日四夜)

Emergency Caesarean Section緊急剖腹分娩

Selected time during operation hours(Monday to Saturday 7:30am – 10:00pm)

手術室辦公時間擇定時間分娩(星期一至六 上午7:30 – 晚上10: 00)

Selected time during non-operation hours (Monday to Saturday 10:01pm – 7:29am,

Sunday and Public Holidays) 非手術室辦公時間擇定時間分娩(星期一至六 晚上10:01 – 早上7:29、星期日 及 公眾假期)

Epidural Analgesia Service無痛分娩 – 脊柱硬膜外麻醉

Nursery Room (per day)

育嬰室 (每日)

Inborn Error of Metabolism screening初生嬰兒先天性代謝病篩檢

Remarks 備註:

• Package accomodation starts from the day of delivery套餐住房由分娩日起計

• Additional 30% of package fee per baby for multiple pregnancies (Caesarean Section Package ONLY)多胎分娩 每位胎兒加收計劃費用之30% (只適用於剖腹分娩計劃)

For Mothers 給媽媽 Free confinement afternoon tea set

坐月午後茶餐 Traditional postnatal confinement practice with ginger water for body cleansing and external use 奉送薑水抺身

Ordering and home delivery service of Pork Knuckles and Ginger Stew 提供薑醋代訂及送貨服務

For the family 給新生家庭

Free parking during the length of stay 在住院期間享有免費泊車Congratulations gift to father, mother and the newborn 給新手爸媽及新生嬰兒的禮物包Mini birthday cake after delivery 慶祝出生的小蛋糕 Child Health Record Book 孩子健康紀錄手冊

Door to Door, GHK-to-home transportation arrangement at discharge* 安排專車送達回家*

Mother 產婦 Stem cell cord blood collection service

收取臍血服務 Vacuum extraction or forceps delivery for vaginal deliveries 輔助分娩: 真空吸引術或產鉗助產

Epidural and spinal anaesthesia, all extra tests, examinations, treatments, and medications prescribed by doctors 無痛分娩及脊髓麻醉，所有由醫生指定的額外化驗、檢查及藥物

Failed induction of labour 引產失敗

Lodger for relative (Standard room) 親友留宿費用 (標準房)

Abdominal binder 托腹帶

Baby 嬰兒 Cord blood for pH testing

臍帶血血氧分析 Phototherapy treatment

黃疸光照治療 Immunoglobulin injection for the baby, for mother with hepatitis B 如產婦患有乙型肝炎，嬰兒出生時注射的乙型肝炎免疫球蛋白

Inborn Error of Metabolism Screening 初生嬰兒先天性代謝病篩檢

Father 父親 Husband’s company in operation theater

父親陪產

All doctors’ fees including obstetrician, paediatrician, anaesthetist and consultation fee of other consultants, ward round fees and emergency cesarean section fee. 所有產科醫生、兒科醫生、麻醉師和其他顧問醫生的會診費、巡房費及緊急分娩的費用

All services beyond routine procedure, such as additional surgical procedures, use of special equipment, blood transfusion, acute and intensive care, isolation, all extra tests, examinations, treatments, and others 所有正常程序以外的服務，如額外手術和使用特別儀 器、輸血、深切治療和隔離等，所有額外化驗、檢查、治療及其他

All antibiotic medications 所有抗生素藥物

Free Special Gifts 小禮物

Excluded Items 不包括項目

* Service is limited to Hong Kong area only but

not available for outlying islands

服務僅限香港範圍地區，不包括離島

Effective date : l / 2 / 2018 Ref: GOBW-POl-Rl-02/18

Normal Vaginal Delivery Package Items 自然分娩套餐

Elective Caesarean Section Package Items 剖腹分娩套餐

Mother 產婦 3 days and 2 nights postnatal accomodation

三日兩夜產後住院

Three standard meals a day 標準 早、午、晚餐

Maternity kit 產婦住院用品包

Maternity admission service, routine fetal monitoring, nursing care 產婦入院檢查、胎兒觀察及護理服務

Delivery Suite Care 享用獨立分娩室待產及生產護理

Blood group type and screening 血型及抗體檢測

Routine drugs and nursing materials 常用藥物及護理用品

Entonox gas for pain relief 安桃樂 (笑氣) 止痛

Routine postnatal observation, nursing care, and treatment 產後護理、觀察及檢查

Postnatal health and infant care education, including breastfeeding and breast milk expression, baby bathing 由專科護士提供產後護理及育嬰指導，如母乳餵哺、嬰兒沐浴等

Mother 產婦 5 days and 4 nights postnatal accomodation

五日四夜產後住院

Three standard meals a day 標準 早、午、晚餐

Maternity kit 產婦住院用品包

Maternity admission service, routine fetal monitoring, nursing care 產婦入院檢查、胎兒觀察及護理服務

All pre-operative preparations 手術前之護理

Blood group type and screening 血型及抗體檢測

Routine drugs and nursing materials 常用藥物及護理用品

Post-operation routine observation, nursing care, and treatment 手術後護理、觀察及檢查

Postnatal health and infant care education, including breastfeeding and breast milk expression, baby bathing 由專科護士提供產後護理及育嬰指導，如母乳餵哺、嬰兒沐浴等

Baby 嬰兒 5 days and 4 nights nursery charges

五日四夜嬰兒房費用

Routine nursery care including the first few hours incubator care, daily baby bathing, cord care, milk formula, and diapers 新生嬰兒護理：包括出生首數小時的保溫箱費用、 沐浴、臍帶護理、奶粉及紙尿片

Newborn Immediate Care 新生兒即時護理

Laboratory test for meonatal screening, such as G6PD, ABO/Rh(D) Group, Thyroid Func-tion Test (FT4, TSH) 新生嬰兒常規化驗: 葡萄糖六磷酸去氫酵素缺乏症 (蠶豆症)、甲狀腺功能、血型及Rh因子測試

Vitamin K injection and initial vaccinations for hepatitis B and BCG 維他命K注射及第一次防疫注射：卡介苗及乙型 肝炎疫苗

Newborn Hearing Screening Test 新生兒聽力篩檢

Jaundice screening in Nursery 住院期間黃疸篩查

Happy baby photo in opertating theater 全家福 (手術室內)

Baby 嬰兒 3 days and 2nights nursery charges 三日兩夜嬰兒房費用

Routine nursery care including the first few hours incubator care , daily baby bathing, cord care, formula milk, and diapers 新生嬰兒護理，包括出生首數小時的保溫箱費用、 每天沐浴、臍帶護理、奶粉及紙尿片

Newborn immediate care 新生兒即時護理

Laboratory test for meonatal screening, such as G6PD, ABO/Rh(D) Group, Thyroid Function Test (FT4, TSH) 新生嬰兒常規化驗， 包括葡萄糖六磷酸去氫酵素缺乏症(蠶豆症)、甲狀腺功能及血型測試

Vitamin K injection and initial vaccinations for hepatitis B and BCG 維他命K注射及第一次防疫注射， 包括卡介苗及 乙型肝炎疫苗

Newborn Hearing Screening Test 新生兒聽力篩檢

Jaundice screening in Nursery 住院期間黃疸篩查

Happy baby photo in Labour and Delivery room 全家福 (分娩室內)

Father 父親 Husband’s company in the Labour and Delivery room

父親陪產

Cutting of the umbilical cord 剪臍帶

Kangaroo care 袋鼠式護理

Father 父親 Husband’s company in the operatating theater (Excluded item)

父親陪產

Cutting of the umbilical cord 剪臍帶

Kangaroo care 袋鼠式護理

Advance Maternity Deposit Reminder

(With effect from 1 January 2019 for all bookings)

Payment Address

and Office Hours

Hong Kong Resident

Overseas Passport Holder

Mainland China Resident (NEP 1 and NEP 1.5)*

Business Office, G/F 9:00am – 10:00pm

(Monday to Sunday)

Labour Ward, 2/F, Tower B For documents checking

9:00am – 5:00pm (Monday to Friday)

Deadline for Paying Deposit

Within one month after the booking is confirmed by obstetrician (Booking will be canceled without prior notice if the deposit is not settled by deadline)

Advance Deposit Amount

Hong Kong Resident

Overseas Passport Holder

Mainland China Resident

HK$10,000 HKD$20,000

Please settle the payment by cash, EPS or credit card

Procedures for Deposit

Payment

Documents required:

Maternity bed booking form (stating the personal particulars of the expectant mother and the expected date of confinement)

Valid identification document of the expectant mother (original copy) as listed below:

Hong Kong Resident

Overseas Passport Holder

Mainland China Resident

Hong Kong identity card

Overseas passport

Exit/Entry Permit for Travelling to and from Hong Kong and Macau

The People’s Republic of China Passport

Marriage Certificate: Certificate of Marriage issued by the Marriage

Registry of Hong Kong; OR Marriage Certificate issued by the People's

Republic of China (PLUS a corresponding notarised document issued by a notary public in the Mainland China, stating the names and identification document numbers of the husband and wife); OR

Marriage Certificate issued in overseas (PLUS a notarised document issued by the respective Consulate-General of the People's Republic of China)

Declaration obtained from the Home Affairs Department (for certification of the genuine marital status between the expectant mother and her husband)

Identification document of the husband NEP 1: Hong Kong permanent identity card NEP 1.5: Hong Kong identity card AND Permit for

Proceeding to Hong Kong and Macao (One-way Permit)

Payment by Authorised

Representative

Hong Kong Resident

Overseas Passport Holder

Mainland China Resident

Payment can be settled by authorised representative

Payment cannot be settled by authorised representative

Expectant mother and the husband must settle the payment in persons

Booking Cancelation

and Refund

Arrangement

Full refund is applicable for the following cases: Less than 34 weeks delivery at hospital under the Hospital Authority Miscarriage For refund under other circumstances, 10% administration fee will be levied from the admission deposit: Hong Kong Resident/Overseas Passport Holder: HK$1,000 Mainland China Resident: HK$2,000

All refund application must be submitted within one month after the expected date of confinement (Overdue application will not be accepted)

Documents required for refund arrangement: Supporting letter by attending obstetrician registered in Hong Kong Medical certificate issued by hospital under the Hospital Authority Original deposit receipt (Missing receipt will not be reissued) Written authorisation letter and supporting identification document of the

authorised representative (if applicable) If the deposit was settled by credit card, the refund will be reimbursed to the

same credit card account Identification document (of the authorised representative) as follows:

Hong Kong Resident

Overseas Passport Holder

Mainland China Resident

Copy of Hong Kong

identity card

Copy of Overseas passport

Original copy of Confirmation Certificate on Delivery Booking (Missing copy will not be reissued)

Copy of identification document of the expectant mother

Admission Reminder

Documents required:

Original copy of the deposit receipt

Admission letter

Antenatal check-up and blood test reports

Others (if any)

Hong Kong Resident

Overseas Passport Holder

Mainland China Resident

Hong Kong identity card

Overseas passport

Confirmation Certificate on Delivery Booking

Exit/Entry Permit for Travelling to and from Hong Kong and Macau

*Remarks:

NEP 1 – Husband who holds a Hong Kong permanent identity card

NEP 1.5 – Husband who holds a Hong Kong identity card and the Permit for Proceeding to Hong

Kong and Macao (One-way Permit)

產科預約按金備忘

(2019年 1月 1日起生效 適用於所有預約)

繳費地點

及

辦公時間

香港居民 持海外護照人士 內地居民 (NEP 1 及 NEP 1.5)*

地下，出入院登記及繳費處

上午 9:00至下午 10:00

(星期一至星期日)

B座二樓產房

登記所須文件

上午 9:00至下午 5:00

(星期一至星期五)

繳付按金

期限

由產科醫生預訂科床位後之一個月內

(未如期繳付按金者，將被視為自願取消本院之產科床位，恕不另行通知)

預約按金

金額

香港居民 持海外護照人士 內地居民

HK$10,000 HK$20,000

請以現金、EPS或信用卡付款

繳付按金

程序

所須文件：

產科預約床位表格 (註明孕婦的個人資料及預產期)

孕婦之有效身份證明文件 (正本) 如下：

香港居民 持海外護照人士 內地居民

香港身份證 海外護照

往來港澳通行證

中華人民共和國護照

結婚證書：

由香港婚姻註冊處發出之結婚證書； 或

國內註冊之結婚證書 (必須出示國內公證婚

姻證明，列出丈夫及孕婦二人的姓名和證

件號碼)； 或

其他國家註冊之結婚證書 (必須出示註冊當

地中國領事館發出的公證婚姻證明/認證)

香港民政處簽發之宣誓紙 (證明孕婦與丈夫的合法

夫妻關係)

丈夫身份證明文件：

NEP 1 : 香港永久性居民身份證

NEP 1.5 : 香港居民身份證 及 前往港澳通行

證 (單程證)

授權代表

繳費

香港居民 持海外護照人士 內地居民

費用可由授權代表繳付 費用不可由授權代表繳付

所有孕婦必須親身與丈夫前往本院繳交按金

取消預訂

及

退款安排

按金可於以下情況獲全數發還：

少於 34週並在醫院管理局轄下醫院分娩

流產

除上述情況外，所有退款申請將收取按金中 10%作行政費：

香港居民/持海外護照人士： HK$1,000

內地居民： HK$2,000

所有退款申請必須在預產期後的一個月內提交 (逾期申請將不獲接受)

申請退款所須文件：

香港註冊產科醫生發出之證明信

醫院管理局轄下醫院發出之證明信

按金收據正本 (如遺失將不獲補發)

書面授權信及授權代表的身份證明文件 (如適用)

如以信用卡繳付按金，按金將退回該信用卡帳戶

(授權代表) 身份證明文件如下：

香港居民 持海外護照人士 內地居民

香港身份證副本 海外護照副本 預約分娩服務確認書正本 (如遺失將不獲補發)

孕婦身份證明文件副本

入院提示

所須文件：

按金收據正本

入院信

產前檢查及驗血報告

其他 (如有)

香港居民 持海外護照人士 內地居民

香港身份證 海外護照 預約分娩服務確認書

往來港澳通行證

*備註：

NEP 1 – 丈夫持有香港永久性居民身份證

NEP 1.5 – 丈夫持有香港居民身份證，並同時持有前往港澳通行證(單程證)，但不包括投資或工作簽證