Lake Butler Hospital
JaxCare Transport Reservation Form
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.
Gender *
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Discharge/Transfer (One Way) or Appointment (Round Trip) *
 
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Calculate Your Charge

Mileage Estimate:
Patient Mobility? For Wheelchair and Stretcher, Maximum of Two (2) Medium Size Stairs At Location or Outside Assistance Will Be Necessary *
Patient Mobility? For Wheelchair and Stretcher, Maximum of Two (2) Medium Size Stairs At Location or Outside Assistance Will Be Necessary *
Number of Miles - if under 30 Miles One Way, Even numbers, no decimals.
Number of Miles - if over 30 miles One Way, Even numbers, no decimals.
Number of Miles - if Under 30 Miles One Way, Even numbers, no decimals.
Number of Miles - if 30 Miles or Over Each Way, Even numbers, no decimals.
Number of Miles - if 30 Miles or more One Way, Even numbers, no decimals.
Number of Miles - if 30 Miles or Over Each Way, Even numbers, no decimals.
Current Total Estimate:
$0.00
Paid By: (JaxCare does not accept Insurance) Only Patient Pay (cash, card, or check) or Bill To Lake Butler Hospital *
Visa

Pickup Location

Pickup Location: *

Dropoff Location

Other Details

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