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Wheelchair or Number
Name
*
First
Last
Email
*
Phone Number
*
Enter your phone number
Number of Riders
*
1
2
3
4
Total number of Riders. Maximum 4 riders per van including person in wheelchair.
Wheelchair Type
*
Manual Chair
Power Chair
Scooter
Other
Date of Trip
*
Enter date of trip
Trip Leg
*
One Way
Round Trip
Multiple
If trip has more than one destination, call or add details in the comment section.
First Leg Details
*
Include pick up and drop off time (allow 15 extra minutes to get to your destination), pick up and drop off address, name of building, suites, other pick up details if necessary.
Return Trip Details
Include pick up and drop off time (allow 15 extra minutes to get to your destination), pick up and drop off address, name of building, suites, other pick up details if necessary.
Comment or Message
Include any other details necessary for example: if transfer assistance is needed, stairs, over 250lbs, extra large chair, any sensitivities, oxygen requirements, service animal, special instructions, etc.
Do you understand and agree to our Terms and Conditions?
*
Yes
No
Cancellations and No-Shows: We understand that circumstances may change, and you may need to cancel or modify your trip. By utilizing our non-emergency medical transportation services, you acknowledge and agree to the following terms and conditions: Payment: Payment for the trip must be completed at least 24 hours prior to the scheduled start time. If a trip is booked less than 4 hours before the pick-up time, any cancellation fees will be enforced immediately if a cancellation is requested. Cancellation Window: Cancellations must be made at least 4 hours prior to the scheduled start time of the trip to receive a full refund. Cancellation Fee: If a cancellation is made after the 4-hour window prior to the pick-up time of the first leg of the trip, a cancellation fee of 50% of the total invoice will be charged. This fee covers administrative and operational costs associated with the cancellation. No-Show Fee: A no-show fee equivalent to the full price of the total invoiced trip will be charged in the event that the rider’s party is not ready for pick-up 15 minutes after the scheduled pick-up time of the current leg of the trip. Definition of No-Show: A no-show is deemed to have occurred when the rider’s party is not ready for pick-up 15 minutes after the scheduled pick-up time of the current leg of the trip. It is important to be punctual to avoid inconveniences and additional charges. Refunds and Disputes: Refunds for cancellations made within the specified time frame will be processed promptly. If you believe that a cancellation fee or no-show fee has been incorrectly charged, please contact our customer service within 7 days to discuss the issue and initiate a potential refund. Rescheduling: In cases where you need to modify or reschedule your trip, please contact our customer service as soon as possible to explore available options. Additional charges may apply based on the revised trip details. By utilizing our transportation services, you acknowledge that you have read, understood, and agreed to these terms and conditions regarding cancellations and no-shows.” Video Surveillance and Audio Recording: For the safety and security of all parties involved, non-emergency medical transportation vehicles may be equipped with video surveillance and audio recording systems. By utilizing our transportation services, you acknowledge and agree to the following: Consent: By boarding the vehicle, you consent to being recorded by video and audio surveillance equipment during your trip. This includes all passengers present in the vehicle. Purpose: The purpose of video surveillance and audio recording is to ensure the safety of passengers, drivers, and property, as well as to deter and address any incidents that may occur during the trip. Privacy: We are committed to protecting your privacy. The recorded footage and audio will be treated as confidential information and will only be accessed and disclosed in accordance with applicable laws and regulations or as required by legal authorities. Storage and Retention: Recorded footage and audio will be securely stored and retained for a specific period of time as required by local laws and regulations. After this period, the recordings may be deleted unless they are needed for legal purposes. Access and Disclosure: Access to the recorded footage and audio will be strictly limited to authorized personnel who require it for legitimate purposes such as incident investigation, law enforcement requests, or as required by court order. Notification: A notice indicating the presence of video surveillance and audio recording may be prominently displayed in the vehicle to inform passengers about the use of such technology. Use of Recordings: Recordings may be used to investigate any incidents, resolve disputes, verify claims, or improve the quality of our services. However, recordings will not be used for any other purpose without your explicit consent, unless required by law. Exceptions to Consent: In certain cases, such as when required by law enforcement or under suspicion of illegal activities, consent to be recorded may not be required. By utilizing our transportation services, you acknowledge that you have read, understood, and agreed to these terms and conditions regarding video surveillance and audio recording during your trip or while in the vehicle.” Please note that this is just an example clause and should be reviewed and tailored to fit the specific requirements and legal framework of your non-emergency medical transportation service. It is always advisable to consult with legal professionals to ensure compliance with relevant laws and regulations. Safety and Responsibilities in Case of Accidents: Your safety is of utmost importance to us. By utilizing our non-emergency medical transportation services, you acknowledge and agree to the following terms and conditions: Safety Precautions: We strive to maintain a safe environment during your trip. Our drivers are trained to adhere to all traffic laws, exercise caution, and prioritize the safety of all passengers. However, unforeseen accidents may occur despite our best efforts. Assumption of Risks: You acknowledge and accept that transportation, whether by road or any other means, carries inherent risks. These risks may include, but are not limited to, accidents, delays, and unforeseen events beyond our control. You voluntarily assume these risks when using our transportation services. Responsibilities of the Transportation Provider: We commit to providing safe and reliable transportation services. In the event of an accident, we will promptly take necessary actions to ensure the safety and well-being of all passengers, including notifying appropriate authorities and providing any required assistance to the best of our abilities. Responsibilities of Passengers: Passengers are expected to act responsibly and follow all safety guidelines and instructions provided by the driver. This includes wearing seat belts when available, refraining from engaging in any activities that may distract the driver, and adhering to all applicable laws and regulations. Reporting Incidents: In the event of an accident or incident, passengers are encouraged to promptly notify the driver and, if necessary, emergency services. This will help ensure appropriate assistance is provided and accurate documentation is recorded. Liability and Indemnification: While we take all reasonable measures to ensure your safety, we cannot be held liable for any loss, injury, or damages resulting from accidents or incidents that occur during your trip. By utilizing our transportation services, you agree to release and indemnify us from any claims, damages, or liabilities arising from such accidents or incidents, to the fullest extent permitted by law. Insurance Coverage: We maintain appropriate insurance coverage as required by law. Any claims or compensation related to accidents or incidents will be subject to the terms and conditions of our insurance policy. Cooperation in Investigations: In the event of an accident or incident, all parties involved, including passengers, are expected to cooperate fully with any investigations conducted by relevant authorities or insurance providers. By utilizing our transportation services, you acknowledge that you have read, understood, and agreed to these terms and conditions regarding safety and responsibilities in case of a
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