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。
Thank you for choosing IM OT Clinic. Please fill out the following form to help us get a better sense of you and your child's backgrounds and needs for early intervention.

填寫後，請您注意陌生來電。如聯繫兩次未果，將傳簡訊通知；若您未回覆簡訊，治療所將不進一步聯繫，請重新填寫預約表單。
Please note that the therapist will contact you with phone call or text. If we don't get any reply, we won't try to contact again. Please fill the form again when you need to make an appointment. Thank you for waiting.
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Email *
聯絡人姓名 / 聯絡單位名稱 Name *
您的需求 / Your need *
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?  *
聯絡電話 / Contact number *
方便聯繫您的時間 / Preferred time to be contacted *
請問您如何得知愛能？ / How did you hear about IM OT Clinic? *
備註 / Notes
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