Your reservation is not confirmed until payment is made
Complete this form and a member of our registration and scheduling team will be in contact. If you need immediate assistance, please call our office at (706) 482-4005
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
me@email.com
Will someone accompany you?
*
YES
NO
Do you need assistance in/out of the vehicle?
*
YES
NO
Will this be a wheelchair transport
*
YES
NO
Appointment Date and Time
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
15
30
45
Minutes
AM
PM
AM/PM Option
Appointment Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pickup Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Multiple Stops
*
YES
NO
One Way or Roundtrip
*
One Way
Roundtrip
Comments
Please be sure to include any information about the appointment in the above comments and make sure that you enter the accurate time. If your appointment suggests that you are to be there 15 minutes ahead of time to complete paperwork, please include this in your appointment time.
~ Thank you ~
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