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Terrace of Gainesville/Isle Health & Rehab
JAX Patient Care Reservation Form
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Appointment Request Made By:
*
Your Phone Number 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
*
Isle Health 1125 Fleming Plantation Blvd, Fleming Island, FL 32003 (904) 541-3500
Terrace of Gainesville 7207 SW 24th Ave Gainesville 32607
Other
Other
Drop Off Location Name
*
DropOff Location Address
*
Dropoff City
*
Jacksonville
Gainesville
Starke
Orange Park
Fleming Island
Jax Beach
Middleburg
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* JaxCare does not provide Oxygen, must be provided by facility. If needed the tank can be returned.
*
Oxygen going with Patient
Wheelchair width over 28" wide
Wheelchair width over 33" wide
Attendant going with
Stairs at residence for pickup or dropoff
None
Other
Other
Other Notes
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