JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Habibi Wheelchair Booking Form
We will contact you shortly. Alternatively, you may contact us on our Hotline: (+65) 8828-1538. You can CALL, SMS OR WHATSAPP whichever floats your boat.
Sign in to Google
to save your progress.
Learn more
* Required
Name
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Wheelchair Type
*
Habibi Mini (Assisted)
Habibi Lightweight (Self-Wheel)
Habibi Prime (Self-Wheel)
Start of rental
*
MM
/
DD
/
YYYY
End of rental
*
MM
/
DD
/
YYYY
Address
*
Your answer
Type of Usage (Refundable Deposit)
*
Choose
Local Use ($100)
Overseas Use ($150)
Other thoughts or comments
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
Forms
This content is neither created nor endorsed by Google.
Report Abuse
Terms of Service
Privacy Policy