Book a Ride Rider's Name * First Name Last Name Phone * (###) ### #### Alternate Phone (###) ### #### Email * Emergency Contact/Caretaker's Name * First Name Last Name Phone Number * (###) ### #### Alternate Phone (###) ### #### Email * Transportation Type Required: * Wheelchair Ambulatory Stretcher Ministry Tracking Number: Only required when using a stretcher between hospitals or nursing homes and is within 24hrs of transfer. Will the Rider be taking a wheelchair or other devices along with them? * Yes No Is the rider able to sit up? * Yes No If Yes, at what angle? Is the rider transferable from stretcher or wheelchair? * Yes No Does the rider use oxygen? * Yes No Date for initial service: * MM DD YYYY Will an attendant be travelling with the rider? * Yes No Age of Rider (approximate): * Pickup Date: * MM DD YYYY Pickup Time: * Hour Minute Second AM PM Appointment Time: * Hour Minute Second AM PM Pickup Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pickup Time After Appointment: * Hour Minute Second AM PM Destination Name (ie: Hospital, Nursing Home, etc...): * Destination Details (i.e. Specialist Name, Wing, Building, etc...): Destination Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referrer's Name (Person who referred this rider): First Name Last Name Referrer's Phone Number: (###) ### #### Company Name: Payment Method: Insurance Claim Cash Cheque Visa Master Card Claim Adjuster's Name: Claim Adjuster's Phone Number: (###) ### #### Claim Reference #: Who to Invoice: Third Party (O.D.S.P., Ontario Works, Veteran Affairs, Blue Cross) Rider Funder Contact Name: First Name Last Name Funder Phone Number: (###) ### #### Funder Company Name: Funder Address: Address 1 Address 2 City State/Province Zip/Postal Code Country Additional Rider Information or Instructions: Thank you! You should hear back from LMTS within one business day.
