ACCESS Trip Request
Complete information is required to book your trip request accurately. Your request may be returned with a request for additional information if incomplete.
E-mail request hours are 9:00 am – 3:00 pm Monday through Friday, and 10:00 am – 2:00 pm Saturday and Sunday for next day service.
No same day service requests via e-mail.
E-mail requests are not guaranteed until you receive an e-mail confirmation.
1.
Client Name
2.
E-mail Address
3.
Date of Trip:
4.
Mobility Aid:
Cane
Walker, Does it fold up?
Wheelchair
Scooter
5.
Do you need the lift?
Yes
No
6.
Pick up Location:
Name:
Address:
Phone Number:
7.
Requested Pick up Window/Time
8.
Destination
Name:
Address:
Phone Number:
9.
Arrival Time
10.
Appointment Time
11.
Return Trip
Location Name:
Address:
Phone Number:
12.
Return trip pick up window / Time
13.
Companion?
Yes, Does your Companion use a mobility aid or lift?
No
14.
PCA (Personal Care Attendant)?
Yes, Does your PCA use a mobility aid or lift?
No
15.
Comments