Schedule a Ride · 1st Touch Medical Transport

1

Member information

Member full name *

Date of birth

Phone *

Email (optional)

Booking on behalf of member?

2

Trip details

Trip type & rate * — determines hold amount

Local one-way ·$40–$70 Round trip <10 mi ·$80–$150 Dialysis round trip ·$80–$120 Weekly dialysis pkg ·$250–$400 Weekly medical pkg ·$400–$500 Other / needs quote

Trip date *

Appointment time *

Pickup address *

Destination *

Each stop is added to the total mileage — charged at the same per-mile rate.

Round trip or one-way? *

One-way Round trip — scheduled return Round trip — will-call (patient calls when ready)

Return trip goes to a different address (not the original pickup)

Expected wait at pickup (minutes)

If your driver needs to wait while you finish an appointment (dialysis, doctor visit, etc.), enter the expected wait in minutes. Prevents your driver from being auto-flagged for a no-show.

Trip purpose

3

Mobility & vehicle type *

Ambulatory (walks independently) Cane / walker Wheelchair Power wheelchair Stretcher Bariatric

Special needs (select any that apply)

Oxygen Escort / companion Spanish-speaking driver Door-to-door assist Curb-to-curb assist Service animal

4

Recurring rides (optional)

For dialysis, therapy, chemo — we’ll assign the same driver where possible for continuity.

Recurring pattern

Recurring end date

5

Payer & notes

How will this ride be paid? *

Private pay / self-pay (card on file) Medicaid (bill through broker) Medicare Advantage plan

Additional notes

Every appointment matters. Let’s get you there.

Member information

Trip details

Mobility & vehicle type *

Recurring rides (optional)

Payer & notes

Every appointment matters.
Let’s get you there.