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UF Health Gainesville
JAX Patient Care Reservation Form
Appointment Request Made By:
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Your Direct Phone Number:
*
Patient Last Name
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Patient First Name
*
Room #
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Gender
*
Male
Female
DOB
*
+
Appointment/Discharge Date
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+
Appointment/Discharge Time
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Is this a recurring trip?
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Monday-Wednesday-Friday
Tuesday-Thursday-Saturday
No
Pickup Location
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North Tower/Shands Hospital 1600 SW Archer Rd, Gainesville 32608
South Tower/ Adult Emergency Room/Cancer Hospital 1515 SW Archer Rd, 32608
East Tower/Heart and Vascular/ Neuromedicine 1505 SW Archer Rd 32608
Psychiatric Hospital/Vista 4101 NW 89th Blvd 32606
Shands Emergency Springhill-8475 NW 39th Avenue 32606
Shands Emergency Kanapaha-7405 SW Archer Road 32608
Other
Other
Drop Off Location Name
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DropOff Location Address
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Dropoff City
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Gainesville
Lake City
Ocala
Starke
Other
Other
Zip Code
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Phone Number at Drop Off Location
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Trip Details
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Round Trip
One Way
Three Legs
Other
Other
Wheelchair or Stretcher?
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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