Vehicle Service Request

MEDICAL APPOINTMENT TRANSPORTATION

Phone 516-792-1735 * Toll-Free: 1-800-716-2799 * Fax 516-256-0092

Reservation Form

To obtain a quote, please e-mail info@medicaltransportationny.com or call us toll free at 1-800-716-2799.

Should you require service within the next 24 hours or need to change an existing reservation you must call our direct line at 516-792-1735

Please Fill in the Following Information

* Required Information

Passengers Name:	*
Phone#:	*
Mobile#:
E-Mail Address :
Emergency Contact :
Emergency Contact Phone#:

Pick Up Information

Pick Up Date:	Month* Day* Year*
Time:	* *
Pick Up Address:	*
City:	*
State:	*
Zip Code:
# of Passengers:
Type of Car:	* Our Sedans & SUVs* are designed for patients who are able to transfer in and out of a transport chair with minimal assistance.*
Transport Chair Required:	Yes No
Pick Up Instructions:

Drop-Off Information

Drop-Off Address:	*
City:	*
State:	*
Doctor or Facility Name:
Doctor or Facility Phone #:

Return Information

Return Date :	Month* Day* Year*
Time of Retun Pickup:	* *
Special Instructions:

Billing Information

Cancellations must be made 24 hours prior to pickup.

Credit Card Type
Credit Card Number:		Exp: (mo/yr) Security Code:
Name on Credit Card:
Card Billing Address:		City:
State/Prov:		Zip/Postal:
Card Holder's Phone:
Additional Information: (special needs, etc.)

Please keep this Credit Card information on file for future services.

Confirmation will be fowarded via e-mail.