Transportation Request - Visiting Angels of Lubbock - Dedicated, Professional In Home Care, Facility Care, and Transportation

in home/facility care

transportation

Visiting Angels Of Lubbock Helps Me Stay Independent

Transportation Request

Please complete this form to request transportation. Note: you must send this at least 24 hours in advance.

Client Information

Name:

A value is required.

Phone Number:

A value is required.

Pickup Address:

A value is required.

Destination Address:

A value is required.

Doctor's Name:

A value is required.

Dr.'s Phone Number:

A value is required.

Who Will Accompany Client To Assist With Paper Work?

Special Notes:

Requester's Name:

A value is required.

Facility Name:

A value is required.

Requester's Phone Number:

A value is required.

Requester's Email Address:
(We will send confirmation to this email address)

A value is required.
Join Our E-mail List? Yes No

Date Of Service:
(Up to 30 days in advance)

Pickup Time:
(Must have 24 hours notice for all requests.)

	:
(HH)	:	(MM)	AM/PM

Is This A Major Holiday?
(ie. Christmas, Thanksgiving, etc.)

Appointment Time:

	:
(HH)	:	(MM)	AM/PM

Out Of Lubbock City Limits:

Mileage From Pickup to Destination: Click Here To Estimate Mileage On Google Maps

Round Trip or One Way:

Ambulatory or Wheelchair:

If Wheelchair Assistance Is Needed

Do They Need A Wheel Chair?

Size:

Motorized? Yes No
Reclining? Yes No

O2 Needed:

Payment Information

Who Is Responsible For Payment:

Payment is due when services are rendered.

Send Invoice? Yes No

Payment Method:

Billing Name:

A value is required.

Billing Phone Number:

A value is required.

Complete Billing Address:

Amount:

Note: you must send this at least 24 hours in advance.
If actual mileage differs from the mileage given on this form, we will charge the difference.
Our O2 will only go up to 5 liters.
We cannot leave any of our equipment with clients.

licensed and dedicated
Visiting Angels of Lubbock is a licensed
franchise of Visiting Angels and licensed
by the State of Texas.

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