Request a Companion 
 预约陪伴服务  
Please provide a few details so we can better understand your needs and recommend a suitable companion arrangement.  

请填写以下简单资料，让我们了解您和家人的需要，并为您建议合适的陪伴安排。

Service Area 服务地区: Kuala Lumpur & Selangor

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Which service do you require? / 您需要哪一项服务？   *
  Preferred service date / 首选服务日期   *
MM
/
DD
/
YYYY
Preferred start time / 首选开始时间  
Time
:
Estimated service duration / 预计服务时长   *
1. Pick-up / Starting Location / 出发地点 *
(Home / Current location / 住家或目前所在地) *
2. Destination / 目的地
(Hospital / Clinic / Other destination / 医院、诊所或其他目的地) *
Age of person receiving the service / 服务对象年龄   *
How does the person usually move around? / 服务对象目前的行动情况是？   *
What kind of support would be helpful? / 您希望我们提供哪些协助？  

Please briefly tell us what kind of companionship or assistance is needed.
请简单说明您希望我们提供的陪伴或协助。
Your name / 您的姓名   *
WhatsApp contact number / WhatsApp 联系号码  
Please include country code (e.g. +60) / 请包含国家区号（例如 +60）  
 *
Your relationship to the person receiving the service / 您与服务对象的关系 *
Submit
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