Haven Hospice
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 *
 +
Discharge/Transfer (One Way) or Appointment (Round Trip) *
 
 +
 +

Calculate Your Charge

Patient Mobility? For Wheelchair and Stretcher, Maximum of Two (2) Medium Size Stairs At Location or Outside Assistance Will Be Necessary *
What County Are We Picking Up? *
 
What County Are We Dropping Off? *
 
Confirm Both Pickup and Dropoff are Outside of Duval and Clay County *
Confirm Both Pickup and Dropoff are Outside of Duval and Clay County *
Mileage Estimate: *
One Way or Round Trip? *
Mileage Charge, Even numbers, no decimals. Origination Point or Destination point must be in Metro Jacksonville. *
Mileage Charge, Even numbers, no decimals. Origination Point or Destination point must be in Metro Jacksonville. *
Mileage Charge, Even numbers, no decimals. Origination Point or Destination point must be in Metro Jacksonville. *
Mileage Charge, Even numbers, no decimals. Origination Point or Destination point must be in Metro Jacksonville. *
Current Total Estimate:
$0.00
Paid By: (JaxCare does not accept Insurance) Only Patient Pay (cash, card, or check) or Bill To Haven *
Visa

Pickup Location

City *
 

Dropoff Location

City *
 

Other Details

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