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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
NameRequired
Person in chargeRequired
AddressRequired
Postal Code 
PhoneRequired(Half-width numbers)
E-mail address
User
NameRequired
Date of BirthRequired
Years Month Day 
AddressRequired
Postal Code 
PhoneRequired(Half-width numbers)
E-mail address
Degree of care requiredRequired
watch overRequired
family attendantRequired
owning a wheelchairRequired
walking independentlyRequired
Desired date of use
Date and TimeRequired
Years Month Day : Minute 
Pick-up destinationRequired
DestinationRequired
MessageRequired
Remarks
Image authenticationRequired
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