PRECIOUS CARE TRANSIT Patient Transportation Intake Form "Where Compassion Rides Along" Client Information Full Name Date of Birth Phone Number Email Address Home Address Emergency Contact Name Relationship Emergency Phone Transportation Request Details Type of Transportation Needed (Select all that apply): Medical Appointment Dialysis Transportation Physical Therapy/Rehabilitation Specialist Appointment Cosmetic Surgery Transportation Post-Operative Follow-Up Appointment Senior Transportation Assisted Living Transportation Other Type: Appointment Date Appointment Time Requested Pickup Time Pickup Information Pickup Address Pickup Contact Person Pickup Phone Number Destination Information Facility/Provider Name Destination Address Provider Phone Number Trip Logistics & Assistance Needs Return Trip Required? Yes No Estimated Return Time Needs assistance entering/exiting vehicle? Yes No Caregiver/family member riding along? Yes No Rider/Caregiver Name (If applicable) Special Instructions Please mention any mobility aids, specific physical limitations, or entry notes: Payment Information Responsible Party Billing/Responsible Party Phone Payment Method Options: Private Pay Facility Pay Family Pay Other Acknowledgment & Consent Important Notice: I understand that Precious Care Transit provides professional non-emergency medical transportation services and functions uniquely to accommodate secure client transits; it does not operate as an emergency ambulance service provider. Patient / Responsible Party Name Electronic Signature Date Signed Submit Intake Form
