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匯款回報及押單登記
匯款回報表單系統(提醒)
--請留意：務必先匯款完成後才填寫表單
--系統收到您的填單後會計人員將於7天內簡訊通知您是否匯款完成
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就診客戶姓名
*
Your answer
就診客戶出生年月日
*
MM
/
DD
/
YYYY
匯款日期
*
MM
/
DD
/
YYYY
轉出帳號後五碼或帳戶戶名
*
轉帳：提供轉出帳號末五碼 / 臨櫃匯款：提供匯款人姓名
Your answer
匯款金額
*
範例：(8,000)
Your answer
手機號碼(輸入格式如：0912-345678)
*
填單後會計人員將於7天內簡訊通知您是否匯款完成
Your answer
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