Follow us on
Facebook
Linkedin
Youtube
Instagram
Eng
简体
Home
Private Nursing
Physio, Occupational, Speech & Cognitive Therapies
Physiotherapy
Occupational Therapy
Speech & Language Therapy
Cognitive Therapy & Memory Training
Diet & Nutrition Counseling
Healthcare & Personal Care Worker Services
Employment
Contact Us
Recent News
Service Request Form
Fields with an asterisk (*) are mandatory
Service Details
Service Setting:
*
Home
School
Hospital
Nursing Home
Organization / Company
Other
Service(s) Requested:
*
Registered Nurse (RN)
Enrolled Nurse (EN)
Healthcare Worker (HW)
Registered Dietitian (RD)
Physiotherapist (PT)
Occupational Therapist (OT)
Speech Therapist (ST)
Cognitive / Memory Training
Personal Care Worker (PCW)
Service(s) Date/ Time:
*
From
Time
To
Time
Service(s) Location:
*
Islands
Kwai Tsing
North
Sai Kung
Sha Tin
Tai Po
Tsuen Wan
Tuen Mun
Yuen Long
Sham Shui Po
Kowloon City
Kwun Tong
Wong Tai Sin
Yau Tsim Mong
Central and Western
Eastern
Southern
Wan Chai
Other Details:
Client/Patient Details
Title:
*
Mr
Ms
Mrs
Full Name:
*
Date of Birth:
Contact Number:
*
English Address:
*
Building/Block:
*
Estate:
Street:
*
District:
*
Islands
Kwai Tsing
North
Sai Kung
Sha Tin
Tai Po
Tsuen Wan
Tuen Mun
Yuen Long
Sham Shui Po
Kowloon City
Kwun Tong
Wong Tai Sin
Yau Tsim Mong
Central and Western
Eastern
Southern
Wan Chai
Area:
*
Hong Kong Island
Kowloon
New Territories
Email Address:
Language:
*
English
Cantonese
Putonghua
Medical History:
*
Good health
Hypertension
Diabetes
Heart disease
Stroke
Asthma
Psychiatric illness
Cancer
Post-operative care
Other
Current Medications:
Level of Daily Activity:
Independent
Partially dependent
Crutches / Wheel chair
Totally dependent
Other
Special Request / Equipment Needed:
Contact Person Details
Title:
*
Mr
Ms
Mrs
Contact Person:
*
Relationship:
*
Mobile:
*
Email Address:
*
Billing Information
Title:
Mr
Ms
Mrs
Full Name:
Contact Number:
English Address:
Building/Block:
Estate:
Street:
District:
Islands
Kwai Tsing
North
Sai Kung
Sha Tin
Tai Po
Tsuen Wan
Tuen Mun
Yuen Long
Sham Shui Po
Kowloon City
Kwun Tong
Wong Tai Sin
Yau Tsim Mong
Central and Western
Eastern
Southern
Wan Chai
Area:
Hong Kong Island
Kowloon
New Territories
Email Address:
Receive Our Information In:
*
English
Chinese
Payment Method:
*
By Cheque
Bank Transfer
Declaration
By submitting this Service Request Form, I confirm that I have reviewed and agree to Life Extension's
Terms & Conditions
contained on the Life Extension website.
*