Transportation Request Form

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Email *

Full name of client *

Transportation Type *

Manual Wheelchair (Will use my own wheelchair)

Electric Wheelchair (Will use my own wheelchair)

Ambulatory/Senior Transportation (No Wheelchair needed)

I need a loaner wheelchair for my trip.

Main contact number *

Must be a mobile #. You'll receive text confirmations and trip detail updates on this number.

Client's weight in pounds (lbs). *

One-Way or Round Trip? *

Up to two caregivers can ride with you at no additional cost

One-Way Trip

Round Trip

Pick Up Address *

# of steps exiting your pick up location *

We're unable to do more than 3 steps for wheelchair users because of safety reasons. We use portable ramps for steps and ramps become too steep above 3 steps.

There's an elevator or wheelchair ramp available.

Client is able to stand and come down/up the steps.

I have more than 3 steps or a special circumstance. Please call me to discuss.

Date transportation is needed *

YYYY

Time you need us to pick you up? *

Allow 10min for loading and wheelchair securement.

Time

Destination Address *

Time of your appointment (if any)

Time

# of steps entering your destination location *

We're unable to do more than 3 steps for wheelchair users because of safety reasons. We use portable ramps for steps and ramps become too steep above 3 steps.

There's an elevator or wheelchair ramp available.

Client is able to stand and come down/up the steps.

There's more than 3 steps or a special circumstance. Please call me to discuss.

If round trip: Estimated return pick-up time

Your driver will pick you up within 30min of this time.

Time

Do we need to contact someone different for payment? If so, please provide the name, email address and phone number of contact for credit card payment if different from the information you provided above:

Use this space to provide us any additional information you think is important for us to know:

Please note booking timeframe can't be guaranteed until payment is submitted. You will receive an invoice at the email you provided so you may process your payment. There's a $15 fee for any canceled (prior to arrival), altered or rescheduled bookings.
*

If we arrive and are unable to provide transportation because of the rider's condition, the location's safety conditions or rider is unavailable the trip will be canceled and a 50% refund will be issued.

Yes: I understand.

We understand delays are inevitable, but in order to avoid delays for our next client(s), we're unable to wait 10min past your scheduled pick up time. There's a surcharge of $15 per every 15 minute block a driver has to wait for you. If you don't want the driver to wait, please notify us, and we'll assign you the next available pick up window we may have. We thank you for your understanding! *

Yes, I understand.

How did you hear about us? *

Returning customer

Google/Internet Search

Facebook/Instagram

Clinic/Facility/Agency referral

Word-of-mouth

Yelp

Other

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