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Empire Care Centers All Facilities
JAXCare Reservation Form
Appointment Request Made By:
*
Email for Confirmation
Patient Last Name
*
Patient First Name
*
Room #
*
Gender
*
Male
Female
DOB
*
+
Approx Patient Weight?
*
Appointment Date
*
+
Appointment Time
*
Pickup Time
*
Is this a recurring trip?
*
Monday-Wednesday-Friday
Tuesday-Thursday-Saturday
No
Pickup
Pickup Location?
*
University Center for Nursing and Healing 3648 University Blvd S, Jacksonville, FL 32216 (904) 733-7440
Orange Park Center for Nursing and Healing 570 Wells Rd, Orange Park, FL 32073 (904) 264-3912
Normandy Center for Nursing and Healing 8495 Normandy Blvd, Jacksonville, FL 32221 (904) 783-3749
Other
Other
Dropoff
Drop Off Location Name
*
DropOff Location Address
*
Dropoff City
*
Jacksonville
Orange Park
Fleming Island
Jax Beach
Middleburg
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
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