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, rate is $30/trip.

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.

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.Enter between 1 and 10 hours. The charge for each hour is $30.

10

Trip Basic Estimate

11

Wheelchair rental status

12

Your trip estimate is ${tripBasic}

Need a wheelchair: {wheelchairRental}
Round Trip: {isThis}
Wait Time: {howLong} Hrs
Need an Electric Stair Chair: {doYou}

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

15

Other instructionsPlease provide any other instructions if needed in this field

16