CONTACT | CareRoute世田谷 | 車椅子タクシー | 新生児タクシー|港区・世田谷区・渋谷区・駒場の介護タクシー・目黒区・中野区・港区

CONTACT / REQUEST FORM

Please note that we do not provide stretcher transport, oxygen tanks, suction machines, or artificial ventilators.

Requester name

Mobile phone number (half-width numbers)

Purpose of use

Wheelchair transport vehicle

For baby

Body weight

Physical disability certificate

Yes

Reservation date required

Departure time

Departure point (boarding address)

Meeting place

Destination address

Destination facility name

Wheelchair

Unnecessary(independent/cane/walker)

Wheelchair (self)

Wheelchair (rental required)

Number of children

Number of child seats required

Age of first child

Age of second child

Age of third child

Number of passengers other than children

Please write anything else you would like to convey.

Sending completed.

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