Booking Form – Teman Malaysia

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Teman Malaysia | Booking Form

This booking form consists of 5 sections:

Section 1: Details of the client and the service recipient
Section 2: Details of the service
Section 3: Client's Permission and Consent
Section 4: Service Recipient Health Declaration
Section 5: Payment Details

Please fill in the required details. For more information about Teman Malaysia and our service, kindly visit https://www.temanmalaysia.com. We look forward to assisting you with our service, thank you!

Details of the Client and the Service Recipient

It is highly encouraged to value transparency throughout this section. The information given will be communicated to the Temanion of this service. Please ensure to give the information as detail as possible.

Full Name of the Client (as per NRIC)*

Client is referred to the person who is in charge of this booking and the payment for this service.

Phone Number of the Client (01x-xxxxxxxx)*

This Service is for ...*

My Self

My Spouse

My Mother / Mother In-Law

My Father / Father In-Law

My Relative

Others

Full Name of Service Recipient (As per NRIC)*

Age of Service Recipient (years)

Phone Number of the Service Recipient (01x-xxxxxxxx)*

Nickname Name of Service Recipient (used in Daily Basis)*

This is to be used by Temanion to interact with the Service Recipient

Age of Service Recipient (years)*

Gender of Service Recipient*

Male

Female

Service Recipient Range of Height (in cm)*

Service Recipient Range of Weight (in kg)*

Health Condition of Service Recipient*

Please include every single details as possible. It is highly encouraged to be transparent with the information given as it is to ensure safety of the Service Recipient and the Temanion throughout the service.

Healthy

Weak

Pregnant

Heart Disease

High Blood Pressure

Diabetes

Dementia

Schizophrenia

Uses urine bag

Lost one/both leg(s)

Severe wound

Other(s)

Please State Other Health Condition of the Service Recipient*

Dependency of Service Recipient*

Independent

Semi-dependent

Wheelchair-bound

Bedridden

Details of the Service

Please select of service to be acquired by Service Recipient*

TEMAN to Vaccination Appointments

TEMAN to Health Appointments

TEMAN to Dialysis Treatments

Ziarah Your Loved Ones

Curated Customized Activities

Date of Service*

DD slash MM slash YYYY

Start Time of Service*

Gender of Temanion Preference*

Male

Female

Any

Language Preference*

Bahasa Malaysia

English

Mandarin

Tamil

TEMAN to Vaccination Appointments*

Our Temanion will assist your loved ones to go to their COVID-19 Vaccination appointment.

TEMAN to Health Appointments*

Our Temanion will assist your loved ones to go to their monthly medical checkup and treatments.

TEMAN to Dialysis Treatments*

Our Temanion will assist your loved ones to go to their dialysis treatment.

Ziarah Your Loved Ones*

When you cannot be there and need someone to look after your loved ones.

Curated Customized Activities*

Our Temanion will accompany your loved ones to anywhere they want to go, or anything they want to do.

Total

Coupon

Plan of Activities*

Please list down all the task that the Temanion requires to do for the Service Recipient. This will be a proof to check and balance and to ensure that Temanion will carry out the tasks which only have been asked by the client.

Mode of Transportation for The Service*

E-Hailing (Taxi, Grab)

Special Mobility Vehicle

Family Members / Relatives

Personal Driver

Teman Malaysia

Other

Other Mode of Transportation for The Service*

Booking of Transportation*

This is to find out who is responsible to make any bookings for transportation throughout the service. Our team will contact you for further clarification and information regarding this.

Handled by the Client

Handled by Teman Malaysia / Temanion, Petty Cash prepared by the Client

Other

Full Name of Driver (as per NRIC)*

Only if the mode of transportation is other than E-Hailing.

Phone Number of Driver*

Only if the mode of transportation is other than E-Hailing.

Meet-Up Location (Full Address)*

Please state the location full address where the Temanion will meet the Service Recipient.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Service Location (Full Address)*

Please state the location, as specific as possible. Example: Kompleks Pakar Rawatan Harian, HKL)

Client's Permission and Consent

I hereby grant Teman Malaysia (the “Company”) the right and permission to use photographs and/or video recordings of me and/or the elderly in my care during the service period on the Company’s websites, publications, promotional flyers, communication materials, derivative works, or for any other similar purposes. I understand and agree that I and/or the elderly in my care may be identified by name and/or title in printed, Internet or broadcast information that might accompany the said photographs and/or video recordings. I agree that all such image files, video and audio recordings, and any reproductions thereof, shall remain the property of the Company. I hereby warrant that I am competent to contract in my own name and that this release is binding on me, the elderly in my care and/or personal representatives.*

Yes, I allow.

No, I do not allow.

Service Recipient Health Declaration

The person in charge (PIC) of filling in this health declaration section on behalf of the elderly is responsible for all information provided. It is reminded that giving false information is an offense under the Prevention and Control of Infectious Diseases Act 1988 (Act 342). The company has the right and responsibility to report such false information.

Full Name of PIC (as per NRIC)*

IC Number of PIC*

Date of Issue*

DD slash MM slash YYYY

Has the service recipient travelled out of the country or across state within the past 14 days?

Yes

Has the service recipient been in contact with anyone who is suspected / tested positive for COVID-19 cluster?

Yes

Has the service recipient had any symptoms of fever, cold, cough, sore throat, difficulty in breathing over the past 14 days?

Yes

I hereby confirm that the service recipient is free from COVID-19 for the past 14 days up until date of declaration issued, and is safe to use the service provided by Teman Malaysia.

Yes, I agree

A Temanion will only be matched when the booking is confirmed. As a confirmation of booking, you are required to make a deposit of RM35.

Our Customer service will contact you back after you submit this form. Thank you.

Teman Malaysia | Booking Form

Details of the Client and the Service Recipient

Details of the Service

Client's Permission and Consent

Service Recipient Health Declaration

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