Pleas fill up all the details correctly

PHOENIX TEKNOLOGIES DELIVERY Transportation Service Request Form

PLEASE FILL OUT FORM COMPLETELY TO AVOID ANY DELAYS.
Full Name

First NameLast Name
E-mail*
example@example.com
Phone Number
Pickup Date/Time

DayMonthYear
Date
Hour MinutesAM/PM Option
Pickup Address
Destination Address
Journey Type
Number of Passengers
Patient must meet the following terms and conditions to be safely transported by Phoenix Teknologies/Delivery:

1) Patient is mentally stable enough to remain in his/her seatbelt during the entire ride.

2) Patient is physically able to get in and out of the vehicle without ANY assistance.

3) Patient is able to take care of him/herself after leaving the vehicle without assistance.
Signature and title of person authorizing transportation for the patient.*

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PHOENIX TEKNOLOGIES DELIVERY Transportation Service Request Form