Medical Courier Service Intake Form

Medical Courier Service Intake Form

Submit your facility's details to begin contract onboarding with Merchant Logistics Solutions. All information is handled securely and in compliance with HIPAA guidelines.
Healthcare Facility or Organization Name
Contact Person's Full Name

First NameLast Name
Contact Email Address
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Facility Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Type of Medical Items for Courier Service

Other
Preferred Service Frequency

Other
Preferred Pickup/Delivery Times
Special Handling or Compliance Requirements (e.g., temperature control, chain of custody)
Would you like to set up a recurring service contract?
Additional Notes or Questions
Should be Empty: