REQUEST FORM

When you call us you will be asked the following questions:

(Please do not feel that your privacy will be compromised, we are following the (HIPAA Privacy Rule standards / PHI (Protected Health Information)) and we want to know more about your situation to accommodate better and to make the trip as comfortable and safe as possible) We safeguard your information and cannot be disclosed to anyone other than yourself.

• Your name
• Your address
• Your Phone #
• Time and Date of your doctor's appointment
• How long do you think the appointment will last?
• Doctor's office or hospital where you are going
• Wheelchair or Gurney Transportation requested
• Type of service: Door to Door, Curve to Curve
• Do you need assistance from your bed to a wheelchair?
• The estimated weight and high
• Do you have your own wheelchair?
• Do you have any specific conditions?
• Any injury or recent surgery?
• Do you need oxygen?
• Do you have your own oxygen cylinder?
• Do you need continuous feeding of oxygen? which level? 1-2-3?
• At your home: Do you live upstairs or on the first floor?
• If stairs assistance needed, How many stairs? are their straight-set or has a landing then stairs?
• If stairs are outside, how many stairs? are there any blocking objects (Plants, bases, etc.)?
• If a gurney needed, can you sit down on your bed?
• Is the hallway wide enough to maneuver the gurney? (sometimes the gurney will fit into the room but cannot be maneuvered in the hallway)
• Are there any steps at the door?
• Is there a ramp at the door?
• Do you use a Standard or Bariatric wheelchair or gurney?
• Is the nurse or family member riding along?
• Do you need bilingual assistance?
• When was the last Covid-19 test done?

We know that seems to be a whole lot of information, when the only thing you need is to be taken to the doctor's office or hospital, but all that information will help us out to allocate resources including the personnel needed to perform the transportation in a safe manner.

Do not worry, you don't have to remember all this, our dispatch will guide you through the process of getting your pick up set-up in our system.

Remember you deserve to be treated with kindness... That is what makes us better.

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