Book Online Form

Book For *

Type of Service Requesting *

First Name *

Last Name *

Email Address *

Patient's Phone Number *

Relationship to Patient *

Patient's Name *

Patient's Age

Customer’s Age *

Customer’s Estimated Weight *

Would You Want The Driver To Wait At Drop-Off? *

Yes

No

Estimated Wait-Time *

0-1 hour

1-2 hours

2-3 hours

3+ hours

Street Number and Name *

Apartment or Suite Number

City *

State *

Zip *

Pick Up Date *

Pick up time *

Appointment time *

Street Number and Name *

Apartment or Suite Number

City *

State *

Zip *

Should we provide a wheelchair?

Yes

No

Do you need wheelchair assistance?

Yes

No

Where do you need assistance

Who are you traveling with caregiver/family

Do you need a Patient Escort Service

Yes

No

Our Patient Escort Service is a non-clinical service provided by Advance Mobility Transportation who will provide physical assistance to and from all doctor’s visits, including being with your loved ones all the time during any doctor’s visits.
Our Patient Escort Service can assist you or your loved ones during doctor visits, grocery shopping, salon/barber visits, and many more.
Our trained Patient Escort Service can assist you or your loved one in transferring to and from any wheelchair.
Our Patient Escort Service will remain with your loved ones at the doctors’ office and be the liaison to provide you all information regarding your doctor’s appointment, and safely take your loved ones through doors, hallways, elevators, to and from any facility you choose.
We will make sure your loved one is taken from inside their home or apartment to any transportation service you choose and ride with them as a dedicated Aid to and from their appointments.
Our Patient Escort Service can assist you or your loved ones at anytime when traveling from one location to another becomes a necessary task.
Do not leave your work, home, or other busy engagements. You can rely on our Patient Escort Service to be there for you and wait for you or your loved one until you arrive or however you may decide.
All of our Patient Escort Service are very compassionate, reliable, sociable, and trained to handle most task you may offer.
Our Patient Escort Service service goal is to cultivate a one-stop long-term relationship, with all our clients.
Book our Patient Escort Service and see the difference. We will work with you and provide any possible flexibility to support your needs.

Receiving Facility Name *

Receiving Facility Phone Number *

Accompanying Person(s) (person must be 18 years old or older)

Additional Information or Brief Description of Service Needed *