Evercare Service Booking Form 服務提交表格

Thank you for contacting Evercare, please find our service details and price along with our Terms and Conditions shown here: https://www.yourevercare.com/service-agreement

Please provide your information and caregiving service requests below so that we can match the most suitable caregiver(s) for you. Thank you.

親愛的客戶, 感謝您早前與我們聯繫，查詢晨曦居家護理服務，以下涵蓋我們的收費表和服務條款。請在我們服務開始配對前細閱服務同意書。https://www.yourevercare.com/zh-tw/service-agreement

為配對更合適的服務人員，請提供以下資料，讓我們可以更清楚了解您的需要。有了您的要求，我們便可開始尋找適合的護理人員資料，同時等候您最後去確認日期和時間。

Contact Person Details 聯絡人資料

Contact Person First name (same as HKID) 聯絡人英文名字 (須與香港身份證相同):*

Contact Person Last name (Same as HKID) 聯絡人英文姓氏 (須與香港身份證相同) :*

Contact Person Email 聯絡人電郵:*

Contact Person Phone number 聯絡人電話:*

Full Residential Address 完整居住地址:*

Billing Address (If different than Residential Address) 帳單地址 (如與居住地址不同)

Care Recipient Details 服務對象資料

Care Recipient's Name 服務對象姓名:*

Care Recipient's Gender 服務對象性別:*

Care Recipient's Address 服務對象地址:*

Care Recipient's Birth Year and Month 服務對象出生年份和月份*

If birth date is unknown, please enter the date as "1" 如果出生日期未知，請輸入日期為 "1"

Year/Month/Day

Care Recipient's Weight 服務對象體重*

Care Recipient's Mobility 服務對象活動能力*

Hospitalization in the past 12 months 過去12個月入院次數*

Service Request 服務要求

Caregiver Rank 護理人員*

Can select more than one 可多選

Start Service Date 開始服務日期*

Year/Month/Day

Preferred Service Time 服務時間*

ie: 8:00AM - 6:00PM

Caregiver Gender 護理人員性別*

Service Language 服務語言*

Can select more than one 可多選

Other Remarks or Instructions 其他備註或指示

If applicable, please select the home care agencies that you have used before 如果適用，請選擇你曾經使用過的居家護理中介:

How did you hear about us? 如何認識我們？*

Referral Doctor's Name

Please read through our service agreement and cancellation policy before e-signing your name below:
https://www.yourevercare.com/service-agreement

在我們為您開始配對服務前，請先點擊以下連結細閱服務同意書和服務取消政策，然後在下方簽署：
https://www.yourevercare.com/zh-tw/service-agreement

On the following days, we charge 2x the rates set above. 我們會於以下日子收取2x費用:

Signature 簽署*

Please use full name as stated in HKID. By stating your full name here you are agreeing to the terms and conditions as laid out in our service agreement.

請使用香港身份證上的全名。在此填寫您的全名，即表示您同意我們服務協議中規定的條款和條件。

Which language would you wish to receive communication in? 您希望以哪種語言進行溝通？*

Cantonese 廣東話

Mandarin 普通話

English 英文