Life Extension is a premium healthcare provider that delivers services to people in the comfort of their own home or setting of their choosing.

By completing and submitting this Service Request Form, you are confirming your request for service and acknowledge that Life Extension will immediately act to identify and confirm staffing for your healthcare needs. We will look to notify you within two (2) business days with the staffing details for your order.
Fields with an asterisk (*) are mandatory

(Office use) Ref

Service Request Form

Date

Applicant Information (Patient / Next-of-Kin):

Name

Address

Tel

Other

Service(s) Date/ Time

From Date:

From Time

To Date:

To Time

Patient Information

Name

Mobile No.

Birthdate

Home No:

HKID

Gender

Male

Female

Address

HKI

KLN

Next-of-Kin

Relationship

Mobile No.

Past Medical History - Others

Past Medical History - Medications

Mobility - Others

Special Request / Equipment needed:

Payments & Billing Information:

Cash

Cheque

Bank Transfer

Credit Card

Name (English)

HKID

Address

Name (Chinese)

Tel

Name (English)

Name (Chinese)

HKID

Address

Tel

I have read and understand Life Extension Company's Terms & Conditions of Service, and I am hereby confirming my service application. I acknowledge that I have received a copy of the Terms & Conditions of Service, which includes information about various charges such as fees for cancellations, as well as other legal obligations. I understand that Life Extension will immediately begin to arrange staffing according to my requests indicated herein, and will work to notify me of staffing details within two business days.

Applicant's Name & Signature

Name

Signature

Updated: 30 May 2023

Are you human?*

This field should be left blank

Life ExtensionCompany Limited ║ G. P.O. Box 8086, Hong Kong ║ +852 2790 7290 ║ info@life-extension.com.hk ║ www.life-extension.com.hk

Service Request

Service Request Form

Applicant Information (Patient / Next-of-Kin):

Contact Information

联系信息

聯絡資訊

Service Request Form

Applicant Information (Patient / Next-of-Kin):

服务申请表格

申请人资料 :

服務申請表格

申請人資料: