Same Day Transports Will Be Call Confirmed Upon Recieving This Request.

Transports Other Than Same Day Will Be Call Confirmed The Day Prior

And Also By Driver When Enroute For Pickup. Please Provide The Proper Phone

Number To Enable This Confirmation and Avoid No-Show At The Door Charges.

Appointment Request Made By: *

Your Phone Number *

Your Email

Patient Last Name *

Patient First Name *

Gender *

Male

Female

DOB * +

Type of Transport *

Discharge

Round Trip or Multi Leg

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)

Wheelchair(or ambulatory) or Stretcher *

Wheelchair(or ambulatory) ($45 Load Fee)

Strecher LoadFee ($125.00)

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

Under 30 Miles

30 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 scheduled 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

Bill To Brooks Rehab Hospital

Other-Explain Other-Explain

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

Pickup Location *

Brooks 3599 University Blvd S 32216 904-345-7600

Other, Complete Below

Pickup Location Name *

Room # if Applicable

Pickup Location Street Address *

Pickup City *

Zip Code *

Driver will call to make contact when enroute, please give accurate number to contact patient or staff to confirm pickup enroute. *

Dropoff

Drop Off Location Name *

DropOff Location Address *

Dropoff City *

Zip Code *

Phone Number at Drop Off Location (Home or Facility) *

Trip Details *

Round Trip

One Way

Three Legs explain in Other

Other Other

Wheelchair or Stretcher? *

Wheelchair

Stretcher

Ambulatory

Wheelchair needs to come with Driver? *

Yes

No

Special Assistance - JaxCare is Non-Medical, for patients with medical conditions such as Ventilator a medical attendant may be necessary. *

Other Notes