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Fernindina Health and Rehab
JAX Patient Care Reservation Form
Appointment Request Made By:
*
Your Direct Phone:
*
Your Email for Confirmation
*
Patient Last Name
*
Patient First Name
*
Room #
*
Gender
*
Male
Female
DOB
*
+
Appointment Date
*
+
Appointment Time
*
Is this a recurring trip?
*
Monday-Wednesday-Friday
Tuesday-Thursday-Saturday
No
Pickup Location
*
Fernindina Health and Rehab 1625 Lime Street, Fernindina Beach FL 32034 904-261-0771
Other
Other
Drop Off Location Name
*
DropOff Location Address
*
Dropoff City
*
Jacksonville
Orange Park
Fleming Island
Fernindina Beach
Jax Beach
Middleburg
Starke
Other
Other
Zip Code
*
Phone Number at Drop Off Location
*
Trip Details
*
Round Trip
One Way
Three Legs
Other
Other
Wheelchair or Stretcher?
*
Wheelchair
Stretcher
Ambulatory
Special Assistance
*
Oxygen going with Patient
Wheelchair width over 28" wide
Wheelchair width over 33" wide
Attendant going with
None
Other
Other
Other Notes
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