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

Reservation Form

To obtain a quote, please e-mail 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

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

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
Pick Up Instructions:

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

Return Date :

Month* Day* Year*

Time of Retun Pickup:

* *
Special Instructions:

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.

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