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 *

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)

Wheelchair(or ambulatory) or Stretcher *

Wheelchair(or ambulatory) ($45 Load Fee)

Strecher LoadFee ($125.00)

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

Under 40 Miles

40 Miles or Over

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($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($10)

Is This Trip One Way or Round Trip, return can be made by phone at appointment *

One Way

Round Trip

Current Total Estimate:

$0.00

Who is paying for trip? *

Patient-Credit Card or Check over phone or at pickup

Facility - please name Facility Facility - please name Facility

Name as it appears on card *

Email Address For Receipt *

Credit Card Type

Credit Card Number

CVV Code

Expiration Date (mm/yy)

Zip Code

Pickup

Discharge Location Name? *

Discharge Location Address *

Pickup City *

Room # if Applicable

Phone for Driver to call enroute *

Dropoff

Drop Off Location Name *

DropOff Location Address *

Dropoff City *

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 come with Driver? *

Yes

No

Special Assistance *

Other Notes