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Booking form
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Hospital’s Form
Booking form
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Booking Information
Date
*
Service Time
*
Day (7:00 AM to 7:00 PM)
Night (07:00 PM - 11:00 PM)
Pickup Time
*
Select time
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
6:00 PM
6:15 PM
6:30 PM
6:45 PM
Pickup Time
*
Select time
7:00 PM
7:15 PM
7:30 PM
7:45 PM
8:00 PM
8:15 PM
8:30 PM
8:45 PM
9:00 PM
9:15 PM
9:30 PM
9:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
Service
*
Select service from drop down
Stretcher
Wheelchair
Patient’s Name:
*
Date of Birth:
Patient’s Weight:
*
Please enter weight in kilograms (kg). This field is used for all calculations.
Patient’s Weight (lb)
lb = kg × 2.20
Pickup Location:
*
Pickup Location
Orlando Rehabilitation Hospital
Adventhealth Altamonte Springs Hospital
Other
Location Name:
Pickup Address:
*
(Location’s name or Address)
Room:
Room number of pickup location
Add Stop:
*
Yes
No
Stop address
*
Drop-Off Address
*
(Location’s name or Address)
Please select Apt,Suite,Room or Department
Apt
Suite
Room
Department
Name/Number
Distance (miles)
*
Distance is showing in miles
Drop-off Pickup Distance (miles)
Trip:
*
One-way
Roundtrip
Dead Mile Charge
First 30 miles are free; then $2/mi thereafter.
Oxygen:
*
No
1L
2L
3L
4L
5L
6L
7L
8L
9L
10L
Isolation or Precaution:
*
Yes
No
Type:
*
Airborne
Contact
Droplet
Covid
Note:
Request by:
*
Service Rate:
Price:
$0.00
Agent’s Name:
*
SAVE