Trip Reservation Request Form
JAX Patient Care Reservation Form
Gender *
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Covid Positive? *
 
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Estimate Your Transport Charge - Not For Billing Purposes or Charge To Patient. Estimate Only-Accurate Calculation Computed by Dispatch System According to Shortest Route Available

Are the number of miles one way........ *
Wheelchair(or ambulatory) or Stretcher *
Wheelchair(or ambulatory) or Stretcher *
Is This Trip One Way or Round Trip, return can be scheduled by phone at appointment.
Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈
Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈
Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈
Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈
Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈
Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈
Current Total Estimate:
$0.00
Who is paying for trip? *
 
Visa

Pickup

Pickup City *
 

Dropoff

Dropoff City *
 
Trip Details *
 
Wheelchair or Stretcher? *
Wheelchair needs to be supplied by JaxCare? *
Special Assistance *
 
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