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愛能職能治療所兒童療育登記表 / IM OT Clinic Appointment Form
您好！歡迎您使用電子登記表。請您先填寫部分資訊，讓我們可以了解您的需求。
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* Indicates required question
聯絡人姓名 / 聯絡單位名稱 Name
*
Your answer
您的需求 / Your need
*
預約療育課程 / Book Early Intervention Evaluation
了解愛能提供的服務內容 / To know the services IM OT Clinic offers
洽談合作事項 / To contact for cooperation
Other:
您傾向在哪一個地點進行療育課程 / Which of our branch do you prefer to have therapy in?
*
愛能天母 / Tianmu branch
愛能大直 / Dazhi branch
兩者皆可 / Both
聯絡電話 / Contact number
*
Your answer
方便聯繫您的時間 / Preferred time to be contacted
*
Your answer
請問您如何得知愛能？ / How did you hear about IM OT Clinic?
*
Facebook
Google Maps
愛能官網 / IM OT Clinic Website
親友推薦 / Friend or family
學校老師推薦 / School recommendation
永安診所轉介 / Hospital or clinic referral
看到招牌 / Signboard
自行網路搜尋 / Google search
Other:
備註 / Notes
Your answer
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