Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Customer InformationName *FirstLastLayoutPhone *Level of Service *WheelchairAmbulatoryIf you selected wheelchair, please specific the type of wheelchair (standard or bariatric). Our ramp is 30 inches wide. We do not transport motorized wheelchairs. You will need to request a standard wheelchair for transport if you don’t have one.Wheelchair RentalYesNoThere is an additional fee for wheelchair rental of $25.00Email *Bariatric *YesNoTrip InformationAppointment Date and Time *DateTimeOne Way or Round Trip? *One WayRound TripIf this is a round trip request in the comments section below, please add the return pick up time.Trip Type *Private PayMedicaidMedicareInsuranceYou can pay by QuickBooks Invoice, Credit Card, Cashapp, Zelle or PayPal. Just let the dispatcher know your preference. For Medicaid/Medicare clients, please be sure to give the dispatcher your reference #, birthdate, Medicaid/Medicare #.If Medicaid or Medicare, enter your TRIP REFERENCE # below:ENTER YOUR MEDICAID/MEDICARE # BELOW:Long Distance Trip? (31 miles or more) *YesNoLayoutPickup Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDrop off Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAdditional Information *Add any additional information that the dispatcher would need to know such as type of wheelchair (standard, bariatric, motorized). We do not transport all motorized wheelchairs. You will need to request a standard wheelchair for transport if you don’t have one. Our ramp is 31.5 inches wide. If you have insurance, you will need to private pay and get reimbursed by your insurance.*Same day reservations may require additional fees Submit
