Wavi NEMT Get A Quote

1

Are you a wheelchair user?* This field is required.

YESNO

2

Are you bringing your own wheelchair?* This field is required.Select NO if you want to rent a wheelchair.

YESNO

3

Select Vehicle Type* This field is required.

Passenger Vans

Specialized Vehicles

4

Do you require an ELECTRIC stair chair?* This field is required.An electric stair chair is used to help you come downstairs without the hassle of walking, rate is $50/trip.

YESNO

5

Trip details* This field is required.Please enter trip details from where to which location

6

Is this a round trip?

YESNO

7

_Round Trip Value

8

_Electric Stair Chair Charge

9

How long will the driver wait for you?* This field is required.The charge is $15 per 30 minutes. Max wait time is 10 hours.

10

How long will the driver wait for you?* This field is required.Enter between 1 and 10 hours. The charge for each hour is $30.

11

Trip Basic Estimate

12

Wheelchair rental status

13

Date* This field is required.

Date

Hour

Minutes

14

Relationship to Patient* This field is required.

Patient's Name

Patient's Age

Please enter your email

Please enter your phone

Who's Filling the Form

15

Other instructionsPlease provide any other instructions if needed in this field

16

* This field is required.

17

Your trip estimate is ${tripBasic}

Need a wheelchair: {wheelchairRental}
Round Trip: {isThis}
Wait Time: {howLong42} Hrs
Trip Distance: {typeA}
Trip Date: {date}

18

Sender Name