subject_line

Trip Reservation Request Form

JAX Patient Care Reservation Form

Appointment Request Made By: *

Your Phone Number *

Your Email

Patient Last Name *

Patient First Name *

Gender *

Male

Female

DOB * +

Covid Positive? *

Yes

No

Other Other

Pickup Date * +

Pickup TIme *

Appointment Time *

Is this a recurring trip?

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

Calculate Your Mileage Here (Some Facilities May Not Allow This Function, Mileage Can Be Computed Easily With Any GPS Smartphone Device)

Are the number of miles one way........ *

Under 30 Miles

30 Miles or Over

Wheelchair(or ambulatory) or Stretcher *

Wheelchair(or Ambulatory) ($50 Base Rate)

Stretcher ($135.00 Base Rate)

Wheelchair(or ambulatory) or Stretcher *

Wheelchair(or Ambulatory) ($75 Base Rate)

Stretcher ($145.00 Base Rate)

Is This Trip One Way or Round Trip, return can be scheduled by phone at appointment.

One Way

Round Trip

Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈

Wheelchair Miles One Way($2.50)

Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈

Wheelchair Miles One Way($3.50)

Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈

Wheelchair Miles One Way($5)

Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈

Stretcher Miles One Way($5)

Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈

Stretcher Miles One Way($7)

Number of Miles if origination or destination point is in metro Jacksonville. Fill in box with round miles, no decimals or partial miles. * 🛈

Stretcher Miles One Way($10)

Current Total Estimate:

$0.00

Who is paying for trip? *

Patient-Credit Card or Check phoned in or at pickup

Credit Card Charge Input Info Below (Encrypted)

Facility - please name facility responsible (name facility below)

Information Regarding Billing:(Facility Name or Patient Contact Info) Information Regarding Billing:(Facility Name or Patient Contact Info)

Name on Card

Email Address For Receipt

Credit Card Type

Visa

Credit Card Number

CVV Code

Expiration Date (mm/yy)

Zip Code

Pickup

Pickup Location Name *

Room or Apartment Number (if Applicable)

Pickup Location Street Address *

Pickup City *

Jacksonville

Orange Park

Fleming Island

Jax Beach

Middleburg

Starke

St Augustine

Hilliard

Gainesville

Ocala

Other Other

Zip Code *

Phone for Driver to call enroute *

Dropoff

Drop Off Location Name *

Room or Apartment Number (if Applicable)

DropOff Location Address *

Dropoff City *

Jacksonville

Orange Park

Fleming Island

Gainesville

Jax Beach

Middleburg

Ocala

Starke

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

Wheelchair needs to be supplied by JaxCare? *

Yes

No

Special Assistance *

Oxygen going with Patient

Wheelchair width over 28" wide

Wheelchair width over 30" wide (Max Width 33")

Attendant going with

None

Other Other

Other Notes

Secured by Formsite

Encrypted