BTG Uber Transportation Request Form
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Is this your first BTG Uber Rideshare request?
Yes
No
Appointment Type
*
Please Select
Medical
Social Service
Other
Name of Business
*
Number of Riders?
*
Uber Pick Up Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Appointment Time
*
Hour Minutes
AM
PM
AM/PM Option
Mobile Phone Number to be used for Uber Communication
*
Please enter a valid phone number.
Format: (000) 000-0000.
Uber Pick Up Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Drop Off Location:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type a question
I understand that BTG or my BTG Community Health Worker (CHW) must have this online form completed no less than 24 hours before the ride is needed.
I understand that it is my responsibility to contact BTG or my BTG CHW if any of the information changes from what was originally requested on the form. If the change is within the 24hr window of the Uber ride, BTG MUST BE contacted by phone. This includes cancellations. Failure to contact BTG in a timely manner may impact future Uber rides.
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