Please fill out the following form to move forward with your trip. There is no need to print this form, as it is all filled out online by entering the answers to the questions in the fields, and pressing submit when finished. This information is required for planning and contractual purposes. We will contact you shortly to finalize the financial portion of your booking after reviewing your form submission (Any forms submitted Monday to Friday after 8pm EST, or on a Saturday/Sunday will be reviewed the following business day). Fields will disappear as you make choices on this form that do not apply to your trip. For any fields that require an answer to which you may not have, please fill in N/A for 'Not Available' in the corresponding field. Please feel free to contact us anytime if you should you have any additional questions or concerns.
Recommendation: If patients are incontinent, it is recommended for the patient to wear hospital gowns during the transport.
Please DO NOT fill out the form in ALL CAPS!
1
Passenger's Name
 ! 
*
2
Gender
 ! 
*
3
Passenger's age
 ! 
*
4
Approximate height (Estimate)
 ! 
*
5
Approximate weight (Estimate)
 ! 
*
7
Additional Rider's Name
 ! 
*
8
Additional Rider's Mailing Address
 ! 
*
9
Additional Rider's Email Address

Does not have email
 ! 
*
10
Does the passenger utilize oxygen
 ! 
*
11
Is the passenger diabetic
 ! 
*
12
Is the passenger currently utilizing any IVs
 ! 
*
13
Is the passenger currently utilizing any special equipment needed during transport (i.e. nebulizer, cpap, suction machine, or feeding pump)
 ! 
*
14
Special Equipment Description
C-pap                Feeding pump
Nebulizer           Trach
Suction machine
 ! 
15
Does the passenger possess a DNR (Do Not Resuscitate) order
 ! 
*
16
Desired Pickup Date & Time (if known)
   
Unknown
 ! 
*
 ! 
18
Type of Departure Location
 ! 
*
19
Departure Facility Name
 ! 
*
20
Departure Facility Address
 ! 
*
21
Departure Facility Phone Number
 ! 
22
Departure room number (If known)
 ! 
23
Departure Facility Contact Person (if known)
 ! 
24
Departure Facility Contact Person Title (if known)
 ! 
25
Departure Facility Contact Person Phone Number (if known)
 ! 
26
Departure Facility Contact Person Email Address (if known)

Does not have email
 ! 
27
Private Residence Departure Address
 ! 
*
28
Type of Destination Location
 ! 
*
29
Destination Facility Name
 ! 
*
30
Destination Facility Address
 ! 
*
31
Destination Facility Phone Number
 ! 
32
Destination Facility Room Number (if known)
 ! 
33
Destination Facility Contact Person (if known)
 ! 
34
Destination Facility Contact Person Title (if known)
 ! 
35
Destination Facility Contact Person Phone Number (if known)
 ! 
36
Destination Facility Contact Person Email Address (if known)

Does not have email
 ! 
37
Private Residence Destination Address
 ! 
*
38
Primary Family Contact Name
 ! 
*
39
Primary Contact Main Phone #
 ! 
*
40
Primary Contact Main Phone Type
 ! 
*
41
Does your cell Phone Receive Text Messages
 ! 
*
42
Primary Contact Additional Phone # (if applicable)
 ! 
43
Primary Contact Additional Phone Type (if applicable)
 ! 
44
Primary Contact E-Mail

Does not have email
 ! 
*
45
Secondary Family Contact Name
 ! 
*
46
Secondary Contact Phone #
 ! 
47
Secondary Contact Phone Type
 ! 
48
Does your Secondary cell Phone Receive Text Messages
 ! 
49
Description of passenger's condition/medical needs or any additional notes
 ! 
*
50
Does the Passenger have any special dietary needs or food preferences?
 ! 
*
51
Please provide details about special dietary needs or food preferences?
 ! 
*
 ! 
 ! 
54
Is the Passenger under Guardianship or a durable Power of Attorney for Healthcare
 ! 
*
55
What is the Guardian's or Power of Attorney for Healthcare's name
 ! 
*
56
Guardian or Power of Attorney for Healthcare's Mailing address
 ! 
*
57
Guardian or Power of Attorney for Healthcare's Email address

Does not have email
 ! 
*
58
Does Passenger possess a Financial Power of Attorney
 ! 
*
59
What is the Financial Power of Attorney's name
 ! 
*
60
Financial Power of Attorney's Mailing address
 ! 
*
61
Financial Power of Attorney's Email address

Does not have email
 ! 
*
62
Is the Credit Card or Check being used to pay for this trip in the Passenger's name?
 ! 
*
63
What is the Person's (Payor) name on the Credit Card or Check that is being used to pay for the trip
 ! 
*
64
What is that Person's (Payor) mailing address
 ! 
*
65
What is that Person's (Payor) email address

Does not have email
 ! 
*
66
Quoted Cost
 ! 
By pressing the Submit Form button, you acknowledge that you understand that the completion of this form does not establish you as a client or customer of Eastern Royal Medical Transport, LLC ("Eastern"), and that you cannot become a client with any guarantees of a service time and date until you have paid a deposit for the requested trip and you have agreed to all of the terms and conditions required by Eastern Royal Medical Transport, LLC. In addition, the completion of this form does not serve or represent any medical record as it is simply used to gauge availability and screen a potential client's needs for a scheduling a transport.
2024
Version: 18.5