Form

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Book Trip*

Same Day Ride

Same Day Ride Fee $25.00

Service Type*

Ambulatory Transport ($30.00 Base + $3.25/mile)

Pick-up Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Destination Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Total Miles Needed*

Total Trip Price

Liability and Indemnification

Non-Emergency Status

The Client acknowledges that TrueNorth Care & NMT LLC provides Non-Emergency Medical Transportation (NMT) and is not licensed or equipped to provide emergency medical treatment, ambulance services, or life support. In the event of a medical emergency, the Provider will contact 911 immediately.

Limitation of Liability

The Client agrees to assume the risks inherent with transportation. The Client shall hold harmless and indemnify the Provider from any claims, demands, or causes of action arising from any injury, damage, or loss sustained by the Client during or in connection with the transport, except those directly resulting from the Provider's gross negligence or willful misconduct.

Client Readiness

The Client affirms they are medically stable and fit for transport by the designated vehicle (Ambulatory or Wheelchair) at the time of service.

Financial Responsibility & Private Pay Acknowledgment

Explicit Private Pay

The Client expressly acknowledges and agrees that this service is private pay. The Client is solely and personally responsible for the full amount of the service charges based on the Provider's current rate schedule. No portion of this service is being billed to, nor is payment guaranteed by, Medicaid, Medicare, or any other government agency or insurance provider.

Rate Acceptance

The Client accepts the current rate structure including the Base Fee, Per-Mile Rate, and Wait Time Fee as disclosed and agrees that mileage will be calculated based on the Provider's documented records.

Cancellation & Service Timeliness

Cancellation Window

Cancellations must be received by the Provider no less than [2 hours] prior to the scheduled pickup time. Cancellations received after this period will be subject to a fee equal to the Base Fee.

No-Show Policy

If the Client is not present or ready for transport within [5 or 10 minutes] of the scheduled time, the service will be canceled and deemed a 'No-Show.' A 'No-Show' will result in a charge equal to the full Base Fee.

Timeliness Disclaimer

The Provider strives for punctuality but is not liable for delays caused by traffic, weather, road conditions, or other unforeseeable events outside of the Provider's direct control.

Electronic Acknowledgment

E-Signature Validation

By electronically signing below, the Client/Guardian affirms that this electronic signature shall have the same legal force and effect as a manually executed signature, and constitutes full acceptance of all terms and conditions of this Agreement.

Signature*

Total*

USDDescription

Credit Card Details
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Credit Card Number	Security Code
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