Appointment

Person to be Picked up *
Contact Person's Name *
Mobile Number *
Pick Up Address *
Destination Address *
No. of Companions if Any?
Method of Transport *
Wheelchair Sedan Stretcher/Gurney
Date of Transport *
Day Month Year
Appointment Time *
HH MM AM/PM

(time you must be at your destination)

Pick Up Time *
HH MM AM/PM

(time you want to be picked up from to go to your appointment)

Round Trip? *
Got Stairs/Steps? *
Number of Steps
Method of Payment *

Approximate Weight if Method of Transport is Stretcher.

Approximate Height if Method of Transport is Stretcher.

Have you received a quote by our dispatch yet? if so, how much?
E-Mail Address *
During the covid-19 pandemic, many homeless and less fortunate people are unable to get to their doctors appointments to receive proper health care due to lack of transportation . With your donation we can make it happen and you can save a life. Please enter the amount you wish to donate and we can add it to your total trip charges.
Notes or Special Instructions

© 2020 RidAid