Wellness Transportation Request

Wellness Transportation Request

Share your trip details to check availability and receive a quote—this is not a booking.
Wellness Programs/Services

Weekday (Mon-Fri)
- Single Trip: $70 (round-trip, door-to-door)
- Daily Trips: (for regularly scheduled services)
  1. Option 1: 3 days at $165 per week
  2. Option 2: 5 days at $190 per week
Weekend (Sat-Sun)
- Single Trip: $70 (round-trip, door-to-door)
Requester
Requester role

Other
Requester name

First NameLast Name
Email
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to rider
Preferred contact method
Passenger Information
Passenger name

First NameLast Name
Passenger phone (if different)
Please enter a valid phone number.Format: (000) 000-0000.
Passenger type
Will an attendant travel?
Number of passengers
Trip Details
Starting address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Destination address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Appointment or required arrival date and time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Approximate return or pickup time

Hour Minutes

AM/PM Option
Trip type
Trip frequency
Days of week for recurring trips
Trip duration
Earliest start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Transportation Fit
Our vehicles are not wheelchair-accessible. We cannot transport a passenger who must remain seated in a wheelchair during the trip.
Can the passenger independently board and ride in a standard passenger van?
Is help needed to or from the van?
Mobility aid used
Practical assistance/needs
Review and Consent
I consent to be contacted about this transportation request

Other
Additional details or instructions
Should be Empty:

Wellness Transportation Request

Requester

Passenger Information

Trip Details

Transportation Fit

Review and Consent