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Conviva Medical Group
Encrypted JAX Patient Care Reservation Form
Appointment Request Made By:
*
Your Email
Patient Last Name
*
Patient First Name
*
Gender
*
Male
Female
Appointment Time (pickup time will be confirmed)
*
DOB
*
Appointment Date
*
Recurring Trip?
*
Mon-Wed Fri
Tues-Thurs-Sat
Daily Monday thru Friday
Not Recurring
Other
Other
Order By
Beach 11744 Beach Blvd, Ste 107, Jacksonville, FL 32246-8476 (904) 265-2050
Callahan 449621 US Highway 301, Ste 110, Callahan, FL 32011-9348 (904) 507-2692
Dunn Ave 1028 Dunn Avenue, Jacksonville, FL 32218-6427 (904) 766-7606
Gateway 5238-16 Norwood Avenue, Jacksonville, FL 32208-5005 (904) 861-1222
Middleburg 1786 Blanding Blvd. Suite 3, Middleburg, Fl 32068-3804 (904) -282-8000
Normandy 7200 Normandy Blvd., Ste 20, Jacksonville, FL 32205-6271 (904) 378-8520
Orange Park 20 Blanding Blvd., Orange Park, Fl 32073 904- 773- 8977
University 25 University Blvd. North, Jacksonville, Fl 32211-7550 904- 900- 3667
Conviva Transportation
Other
Other
Pickup
Pickup, Street Address
*
Pickup City
*
Jacksonville
Orange Park
Fleming Island
Jax Beach
Middleburg
Starke
Hilliard
Other List City
Other List City
Pickup Zip Code
*
Phone
*
Dropoff
Dropoff At Location Selected?
Beach 11744 Beach Blvd, Ste 107, Jacksonville, FL 32246-8476 (904) 265-2050
Callahan 449621 US Highway 301, Ste 110, Callahan, FL 32011-9348 (904) 507-2692
Dunn Ave 1028 Dunn Avenue, Jacksonville, FL 32218-6427 (904) 766-7606
Gateway 5238-16 Norwood Avenue, Jacksonville, FL 32208-5005 (904) 861-1222
Middleburg 1786 Blanding Blvd. Suite 3, Middleburg, Fl 32068-3804 (904) -282-8000
Normandy 7200 Normandy Blvd., Ste 20, Jacksonville, FL 32205-6271 (904) 378-8520
Orange Park 20 Blanding Blvd., Orange Park, Fl 32073 904- 773- 8977
University 25 University Blvd. North, Jacksonville, Fl 32211-7550 904- 900- 3667
Hilliard
Other List City
Other List City
Drop Off Location Name
DropOff Location Address
Dropoff City
*
Jacksonville
Orange Park
Fleming Island
Jax Beach
Middleburg
Starke
Hilliard
Other List City
Other List City
Zip Code
*
Phone Number at Drop Off Location
*
Trip Details
*
One Way
Round Trip
Discharge
Three Leg
Other (Explain)
Other (Explain)
Third Leg Address:
Wheelchair or Stretcher?
*
Wheelchair
Stretcher
Ambulatory
Wait Time Approved?
*
Yes
No
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