subject_line
Azura
Encrypted- JAX Patient Care Reservation Form
Appointment Request Made By:
*
Patient Last Name
*
Patient First Name
*
Gender
*
Male
Female
DOB
*
+
Appointment Date
*
+
Appointment Time
*
Pickup Location
*
Azura Vascular Center 2416 Dunn Ave Jacksonville 32218
Other (Address, Zip Code, Phone #)
Other (Address, Zip Code, Phone #)
Dropoff Location
*
Azura Vascular Center 2416 Dunn Ave Jacksonville 32218
Other (Address, Zip Code, Phone #)
Other (Address, Zip Code, Phone #)
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
Encrypted