• Client Transport Safety & Consent

    Complete your details, safety information, and consent, then sign electronically to authorize non-emergency transportation.

  • About You

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Safety Information

  • Driver / Staff Safety Notice: If any urgent symptom is checked or the client appears unstable, pause transport, follow emergency procedure, and contact EMS when indicated. This form is not a medical assessment.

  • History of withdrawal seizure or delirium tremens (DTs)?*
  • History of overdose or Narcan use?*
  • Current urgent symptoms*
  • Advance directive / DNR?

  • Consent & Signature

  • I voluntarily consent to non-emergency transportation by Wings to Recovery LLC. I understand transportation has ordinary risks, including traffic collisions and unexpected medical or behavioral events.

    I authorize Wings to Recovery personnel to seek emergency assistance when reasonably necessary and to share the health, medication, substance-use, emergency-contact, and other information on this form with EMS, fire, law enforcement, receiving facilities, or other responders when needed for my safety or care.

    To the fullest extent permitted by law, I release Wings to Recovery LLC and its employees/contractors from claims arising from ordinary negligence related to the transport. This does not release gross negligence, reckless or willful misconduct, or any liability that cannot legally be waived.

    I understand Wings to Recovery is a transportation/support service and not a medical provider. I am responsible for my medications and personal property unless otherwise agreed.

  • Signed Date/Time
     - -

  • Client Answers Review

  • 🚨 REVIEW BEFORE TRANSPORT — Withdrawal seizure/DT history: YES

  • 🚨 REVIEW BEFORE TRANSPORT — Overdose/Narcan history: YES

  • 🚨 REVIEW BEFORE TRANSPORT — Urgent symptom reported

  • 🚨 REVIEW BEFORE TRANSPORT — Advance directive/DNR: YES

  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • History of withdrawal seizure or delirium tremens (DTs)?
  • History of overdose or Narcan use?
  • Current urgent symptoms
  • Advance directive / DNR?

  • Driver Review

  • Witness Date/Time
     - -
  • Should be Empty: