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
Yes
Should be Empty: