Schedule Transportation Service

Please use the form below to schedule your transportation service.  All questions are required

  • *Are you a medical facility scheduling on behalf of a patient?
    *Use a wheelchair?
    *Is the Wheelchair extra large?
    *Facility Name:
    *Contact Name:
    *Facility Phone Number
    *Facility Ext#
    *Facility Fax Number
    *Patient First Name:
    *Patient Last Name:
    *Patient Contact Number:
    *Is the Patient a Male or Female?
    *Do you require one way or round trip service?

    This will ensure you will receive the best pricing.

    *Is your trip a total of 12 miles or less?
    *How many additional miles will the trip be?

    Need Help with total miles?

    To calculate the total miles for your trip using Google Maps, start by clicking on the link to Google Maps, then enter your starting location and destination into the search bar. Once both are set, click "Directions," and Google Maps will generate the best route options, displaying the total distance in miles (or kilometers) and estimated travel time. If you have multiple stops, you can click “Add destination” to include them and see the updated distance. Google Maps makes it easy to adjust routes and view the exact mileage for your entire trip in just a few clicks.

    Click Here to be take to Google Maps

    *Is this an after hours appointment?

    After-Hours (7:00pm to 6:00am) applies to pick up times and drop off times. 

    *What address should we pick you at?
    *Pick up Time?
    *What address are we taking you to?
    *Appointment Time?
    *Is there a time we should pick you back up?
    *Back Time?
    *Will there be anyone traveling with you?
    *Name of Attendant/Escort?
    *Do you have illness or medical condition that requires personal protection equipment?
SKU: SM-260 Categories: ,