Schedule a Ride Call us today at (704) 992-7433Or fill out the form below to schedule a ride. Name * First Name Last Name Email Phone * (###) ### #### Emergency Contact Name * First Name Last Name Emergency Contact Phone * (###) ### #### What services are you interested in? Ambulatory Transportation Wheelchair-Accessible Transportation Wait and Return Services Facility Partnership Date of Appointment MM DD YYYY Requested Pick-up Time Hour Minute Second AM PM Return Ride Needed? * Yes No Requested Return Time Hour Minute Second AM PM Pick-Up Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Type of Location * Home Townhouse Apartment/ Condo Facility Drop off Location * Address 1 Address 2 City State/Province Zip/Postal Code Country Name of Facility or Doctor's Office Special Instructions Appointment Time Hour Minute Second AM PM Rider Needs * Ambulatory Wheelchair Will someone accompany the rider? * Yes No Does the rider require assistance from door to door? Yes No Any special equipment or mobility aids? (Walker, Oxygen tank, etc) Yes No If yes, what type? Who is responsible for the payment? * Notice: The Doctor Ride is a private pay transportation provider. We do not bill Medicaid, Medicare, or any insurance providers at this time. All rides must be paid directly by the rider, their family, or a sponsoring facility prior to service. Client Family Facility Additional Notes/ Requests Anything else that you would like us to know to help better prepare for your ride. We are working on scheduling your ride and will be in contact as soon as possible..
