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Request to use HK Nursing Care Taxi

When applying

■ Please read the Privacy Policy and fill out the inquiry form only upon agreement.
■ Be sure to enter a valid phone number (home or mobile phone) in the phone number field.
■We will call you as soon as we confirm your application.
■ Please check your settings (spam settings), etc. so that you can receive reply emails.
■ If you do not receive a reply from us, we apologize for the trouble and ask that you please contact us again.
■ If you would like to use the service on a regular basis, please let the receptionist know when you call back.


Application form

Introducing company
Name  ※Required
Person in charge  ※Required
Address  ※Required
Postal Code 
Phone  ※Required
(Half-width numbers)
E-mail address
User
Name  ※Required
Date of Birth  ※Required
Years Month Day 
Address  ※Required
Postal Code 
Phone  ※Required
(Half-width numbers)
E-mail address
Degree of care required  ※Required
watch over  ※Required
family attendant  ※Required
owning a wheelchair  ※Required
walking independently  ※Required
Desired date of use
Date and Time  ※Required
Years Month Day Hour Minute 
Pick-up destination  ※Required
Destination  ※Required
Message  ※Required
Remarks
Image authentication  ※Required
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