WHEELCHAIR + AMBULATORY
TRANSPORTATION

Schedule a ride for yourself or someone else. Sameday or future appointments available.

Traveler's Full Name

Phone

Pickup Address

Destination Address

Pickup Date and time

Month

Day

Year

Time

HoursMinutes

Service / Trip Type

Wait Time

Add Equipment or Assistance (Optional)

Bed Assistance with Hydraulic Lift – Bed to Bed (Passenger needs help out of bed at pickup and back into bed on return) – $100

Bed Assistance with Hydraulic Lift – Bed to Room (Passenger will need help getting out of bed at their origin address) – $75

Bed Assistance with Hydraulic Lift – Room to Bed (Passenger will need help getting into bed at the destination address) – $75

Wheelchair Restraint Harness (for travelers with a history of sliding – must be placed in the chair before seating) – $20

Reclining Wheelchair – $40

Additional Information (Optional)

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