Anita's Medical Courier - Independent Contractor and Delivery Service.

Medical Courier Pickup Request

Anita's Medical & Local Business Courier Service | Phone: 210-845-8343 email: anitamedicalcourier@yahoo.com
Welcome to Anita’s Medical Courier and Delivery Service – your trusted, certified independent medical courier proudly serving San Antonio and surrounding areas. With certifications in Bloodborne Pathogens, OSHA, HIPAA and a TWIC card.

How does this work?

It's simple! Fill out the form below with your medical delivery needs. Once received you will be sent a detailed price invoice. If you have any questions email me at: anitamedicalcourier@yahoo.com
Privacy notice: Please do not enter patient names, dates of birth, diagnoses, medical-record numbers, or other protected health information (PHI) in this public request form. If PHI must accompany a delivery, use your facility's approved secure process.
1.) Facility Information

Completing this form will provide an accurate quote for your request.
Name of Medical Facility / Company
Medical Facility Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person / Requestor

First NameLast Name
Department / PO / Reference Number
Contact / Facility Direct Number
Please enter a valid phone number.Format: (000) 000-0000.
This is a

Other
If Other Name of Other
2.) Service Requested
Choose one of the following
3.) Pickup
Pickup Facility / Address

Pickup Facility Name

Address / Dept. / Suite

CityState / Province

Postal / Zip Code
This is a

Other
Pickup Contact Name

First NameLast Name
Pickup Contact Title and Department
Pickup Contact Direct Number
Please enter a valid phone number.Format: (000) 000-0000.
Pickup Contact Email
example@example.com
If Necessary, Secondary/Alternate Pickup Contact (alternate, back-up or witness)

First NameLast Name
Secondary/Alternate Pickup Title and Department
Secondary/Alternate Pickup Contact Direct Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary/Alternate Pickup Email
example@example.com
Request Pickup Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Request Pickup Time

Hour Minutes

AM/PM Option
What type of package is this?
If other, name of other
Are any of the items temperature controlled? Please be sure all temperature controlled items are properly packaged and in temperature control container by the medical facility.
4.) Delivery
Delivery Facility / Address

Facility Name

Street Address Line 2
CityState / ProvincePostal / Zip Code
Delivery Contact Name

First NameLast Name
Delivery Facility Main Number
Please enter a valid phone number.Format: (000) 000-0000.
Recipient Main Contact Email
example@example.com
This is a

Other
Name of other
Required Delivery Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Required Delivery Time

Hour Minutes

AM/PM Option
5.) Package Information
Material Type
Number of Packages / Containers
Approximate Weight
Temperature / Handling
If other, name other
Temperature-Controlled Medical Transport
We provide reliable transportation of properly prepared and sealed temperature-sensitive healthcare items, including medical specimens, laboratory materials, medications, and other temperature-controlled medical products.

To ensure proper handling and temperature integrity, all temperature-sensitive items must be provided to our courier in a sealed, properly prepared, temperature-controlled container by the medical facility, laboratory, pharmacy, or other authorized client.

Our courier will maintain the integrity of the sealed container during transportation and deliver it promptly to the designated receiving facility.

Client Responsibility: The originating facility is responsible for proper packaging, sealing, labeling, temperature requirements, and preparation of the contents prior to courier pickup.
Do you provide the sealed, prepared, temperature-controlled cooler/container for your specimens including any frozen transport that require dry ice for specimens?
Please check all that apply:
Any Additional Information Needed for Safe Transport of Ambient, Refrigerated or Frozen Contents Courier needs to know?
Non-PHI Special Instructions (parking, entrance, department, handling or access instructions only. Do not enter patient information.)
6. Documentation
Documentation Type Required/Requested
Submitting this form sends the request to Anita Medical Courier by email. Submission is a request for service and/or to receive price quote. It does not by itself confirm courier acceptance or pickup time until price is agreed upon and an updated form/email is sent confirming this. Do not enter patient names, dates of birth, diagnoses, medical-record numbers, or other PHI.
Requestor / Preparer Of This Form

First NameLast Name
Title and Department
Email
example@example.com
Today's Date
Should be Empty:

Medical Courier Pickup Request

1.) Facility Information

2.) Service Requested

3.) Pickup

4.) Delivery

5.) Package Information

6. Documentation