Service Request Form

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Click2Health is a healthcare provider and we specialize in Home Health Care and Nursing Procedures. Our services are given by trained professional include all nursing procedures and specialized nursing care. Our nurses are skillful in managing elder patients, post-hospitalization and post-surgical patient in the comfort of your home. Our caregivers take of all daily-living activities for our patients in their homes ensuring they are comfortably looked after. Our nurse managers and nurse supervisors ensure that our professional care is delivered as per our Standard Operating Procedures (SOP) and our Clients are receiving the care as determined.

Need a Nurse or a Caregiver? Please fill up the form and we will quote your accordingly. Thank you.

For detailed enquiries,
Kindly Contact us at
Office number:- +603-5613 5587
Mobile number:- +6011-1123 8034
Email Address:- careline@click2health.com.my

Email *

Patient Name *

I/C Number *

Person In Charge (Contact Person) *

Contact Person's Mobile Number *

Patient is currently living with?

Alone

with family members/ relatives

Other:

Clear selection

Type of service required *

24 hours care

12 hours care

Stay in

Home Nursing Procedure

Other:

Is there a designated place for our staffs to stay if needed?

Yes

Maybe

Clear selection

Care Provider Preferences *

Male Health Care Provider

Female Health Care Provider

No Preference

Other:

Care Period *

Ad-Hoc Basis

Short Term Care

Long Term Care

Other:

Patient Mobility *

Can move around with his/her own ability

Able to walk with assistance of people or equipment such as walking frame, etc.

Bed Bound

Other:

Food intake *

Able to eat on his/her own

Need assistance in feeding

Tube Feeding

Other:

Additional Services required ( can select more than 1)

Visiting Doctor to home

Physiotherapy sessions

Nutrition consultation and dietary plan

Other:

Thank You for the request!

Submit

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