subject_line
OptumServe
JaxCare Quote Invoice
Patient Last Name
*
Patient First Name
*
Gender
*
Male
Female
DOB
+
Appointment Date
*
+
Pickup Time
*
AM
PM
Is the trip One Way or Round Trip
*
One Way
Round Trip
Ambulatory/Wheelchair or Stretcher (under 30)
*
Ambulatory or Wheelchair
Stretcher
Base Fee Total All Legs
*
Total Mileage Charge Round Trip if Applicable
*
Wait Time Charge
Total Trip Charge
$0.00
Calculate
Other Notes
Cancellation Charges
24 Hours Prior to Reservation $25 Booking/Cancellation Charge
Day of Reservation $65 Ambulatory or Wheelchair $145 Stretcher