Niagara Patient Transfer Request Form

Name
Person requiring transportation
Contact Name (only if different)
Type of Service
Medical Conditions
How do you prefer to be contacted?
If contact by telephone is requested, a representative may use email method - depending on time of day or unresponsive telephone calls. (busy signal,etc)
Phone Number

Area CodePhone Number
Email
Transfer Date (Leave if Unsure)
Transfer Time (leave if unsure)
Pickup Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Facility or Destination Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Transfer Details - Include any instructions that will help.
Return Transfer ?
Are You travelling with escort?
Oxygen Required
Weight over 250 lbs?
Insurance (includes government departments)
Type of payment
You agree to the Term and Conditions.
Should be Empty: