subject_line
Azura
Encrypted- JAX Patient Care Reservation Form
Appointment Request Made By:
*
Patient Last Name
*
Patient First Name
*
Gender
*
Male
Female
DOB
*
+
Patient's Phone Number
*
Patient's Secondary Phone Number
Appointment Date
*
+
Appointment Time
*
AM
PM
Pickup Location
*
Azura Vascular Center 2416 Dunn Ave Jacksonville 32218
Other (Street Address, City, State, Zip Code)
Other (Street Address, City, State, Zip Code)
Is this an Apartment? If so, what is the apartment number and building number?
*
🛈
Dropoff Location
*
Azura Vascular Center 2416 Dunn Ave Jacksonville 32218
Other (Street Address, City, State, Zip Code)
Other (Street Address, City, State, Zip Code)
Is this an Apartment? If so, what is the apartment number and building number?
*
🛈
Trip Details
*
Round Trip
One Way
Three Legs
Other
Other
Ambulatory, Wheelchair, or Stretcher?
*
Ambulatory
Wheelchair
Stretcher
Special Assistance
*
Oxygen going with Patient
Wheelchair standard width (28" wide or smaller)
Wheelchair standard width (33" wide or larger)
Attendant going with?
None
Other
Other
Other Notes
Encrypted