Non-Emergency Medical Transportation

*This form must be submitted 24 Hours in advance of the appointment for a quote and to be scheduled*

Please fill out the form completely. Please note that an extra attendant (two-man) is required if the customer weighs more than 180lbs or if there are more than two stairs involved.

TRIP INFORMATION Standard Priority Priority (Fees apply) ONE WAY TRIP ROUND TRIP WAIT/RETURN MULTI-DESTINATION Requested Pick-up Date:   Requested Pick-up Time: 01 02 03 04 05 06 07 08 09 10 11 12 : 00 05 10 15 20 25 30 35 40 45 50 55 60 AM PM TRANSPORTATION DETAILS Wheelchair-Standard Wheelchair-Wide Stretcher Leg Extension Needed Ambulatory Extra Attendant Needed Stairs (more than two) Has Own Wheelchair?                             Type-> DOCTOR/PCP INFORMATION Name: Phone # Appointment Time: 01 02 03 04 05 06 07 08 09 10 11 12 : 00 05 10 15 20 25 30 35 40 45 50 55 60 AM PM * Allow a minimum of 45 minutes between pick-up time and appointment time. PATIENT INFORMATION Name: DOB: Phone # Weight (lbs) First time using MTS? Yes   No
Your Name:	Contact Phone:
Notes/Special Needs/Et cetera:
Pick-up Address	1st Destination Address	2nd Destination Address
Facility: Address: City: Zip Code: Room # Phone # Contact Person	Facility: Address: City: Zip Code: Room # Phone # Contact Person	Facility: Address: City: Zip Code: Room # Phone # Contact Person
Would you like an email confirmation of the request? No Yes Email Address IMPORTANT:Cancelation Policy Passengers are encouraged to cancel scheduled rides at least 24 hours in advance if possible. Any cancellation received later than 24 hours prior to the scheduled pick-up will be considered a late cancellation and will be Charged 50% of the amount of the trip. Submit