Schedule Wheelchair Transport

"*" indicates required fields

Patient's Name*
Medicare A/100 Day Stay*

Please Provide Face Sheet For Patient

MM slash DD slash YYYY
Whose Wheelchair*

We cannot accommodate wheelchairs over 30” wide; most powerwheelchairs are not suitable for transport.

Address*
Address*

(*Please note if this transport is a wait and return additional charges may apply* the first 30 minutes are included in the facility rate) ****Over this will be charged $60.00 per 15 minutes increments****

Facility Payment Agreement

(Sign with your mouse, touchpad or touch screen to sign)

Schedule A Transport