IntuLife Booking Form

1

Form Filler's Name* This field is required.

First Name

Last Name

2

Form Filler's Email* This field is required.

example@example.com

3

Form Filler's Contact Number* This field is required.

Please enter a valid phone number.

4

Payment Type* This field is required.

Facility/Hospital Pay

Patient/Rep Pay

5

Payee's Name

First Name

Last Name

6

Payee's Contact NumberThis is taken to process payment over the telephone.

Please enter a valid phone number.

7

Passenger Name* This field is required.

First Name

Last Name

8

Estimated Passenger Weight (lb)* This field is required.

9

Type of Transport Required* This field is required.

Wheelchair

Gurney

10

Trip Type* This field is required.

Round Trip

One Way

11

Pickup Address* This field is required.

Street Address

City

Zip Code

Country

12

Pick-Up Suit/Unit* This field is required.

13

Pick Up Date* This field is required.

Date

14

Pick Up Time* This field is required.

15

Appointment Time* This field is required.

16

Return TimeIf unknown return time an additional call out charge will be applied

Type N/A if one way transport

17

Drop-off Address* This field is required.

Street Address

City

Zip Code

Country

18

Drop off Unit/Suit* This field is required.

19

Do you need us to bring our own wheelchair?* This field is required.If the trip is a one way and patient doesn't have their own wheelchair

YESNO

20

Does the Patient have any other medical equipment?* This field is required.

YESNO

21

Please provide details of the other medical equipment or special requests.* This field is required.

22

COVID-19 Status

POSITIVE

NEGATIVE

23

Booking ID

24

Intulife Medical Transport Terms and Conditions* This field is required.Please be advised that all patients are assumed to be able to stay in a wheelchair/gurney for extended periods of time and fulfill the criteria for a non-emergency transport candidate. No charge for rescheduling or cancelling a reservation 48 hours before booking. Cancellation within 24 hours/No-shows: will be charged at full rate of fair. Cancellation within 48 hours will be charged 100$ cancellation fee. Unless a specific return time is requested, pick up time is automatically set to one hour ahead of the doctor’s appointment and return time is set to one hour after the start of that appointment. No extra time is added for a 15mins before or after each specified pick up/drop off time. Wait time is charged at 1$/min each minute beyond the first 15mins after each pick up/drop off scheduled time. In the carrier’s reasonable opinion, any passenger soils the vehicle as to render it in a non-presentable condition for further use, a cleaning charge of $100 will be assessed against that passenger or passengers. Vehicles are carefully inspected by the driver prior to each trip; any damage to seats, windows, or other equipment or parts of the vehicle which is caused by any passenger(s) shall be the responsibility of that passenger(s) and the costs to carrier for the repair of such damages shall be paid by the passenger(s). Tolls, fees and special charges shall be paid as an add on to the calculated charge. Carrier reserves the right to refuse to transport a person or persons that are unable to listen to and follow instructions, under the influence, or who is incapable of reasonably taking care of himself or herself, or who shows conduct that threatens the safety of staff or equipment during the journey otherwise the presence of a Carer is required to contain any unforeseen problems that may arise during a ride. Carrier will not be liable for delays caused by Acts of God, public enemies, authority of law, quarantine, perils of navigation, riots, strikes, accidents, breakdowns, bad conditions on the road, snowstorms, and other conditions beyond its control. Pick-ups and drop offs are estimated times, we endeavor to arrive to our patients in a timely fashion, we only guarantee timely arrival to your doctor's appointment or your money back. Carriers are not liable for any risk associated with help needed during loading and unloading a patient, we are a curb-to-curb service and any help requested will carry a full release of liability for Intulife LLC and our affiliates. Except as otherwise specified below, all actions, disputes, claims and controversies under common law, statutory law or in equity of any type or nature whatsoever, whether arising before or after the date of this Agreement, and whether directly or indirectly relating to: (a) this Agreement and/or any amendments and addenda hereto, or the breach, invalidity or termination hereof; (b) any previous or subsequent agreement between the parties; and/or any other relationship, transaction or dealing between the parties (collectively the “Disputes”), will be subject to and resolved by binding arbitration pursuant to the Arbitration Rules of U.S. Arbitration & Mediation. Any award or order rendered by the arbitrator may be confirmed as a judgment or order in any state or federal court of competent jurisdiction, which includes within the federal judicial district of the residence of the party against whom such award or order was entered. Terms and conditions are subject to change without notice. Initial below to agree with our T&C's.

I Agree to the terms and conditions