Book a Ride
at Serenity Medical Transport
Please fill out the form below,
and we'll get back to you within as soon as possible!
Is this ride for you or someone else?
Me
Someone Else
Client Information
First Name
Last Name
Email Address
Weight of client
Phone Number
Transportation date
Pick Up Address
Street Address
City
ZIP Code
Facility
Pick Up Time
Drop off Address
Street Address
City
ZIP Code
Facility
Drop off Time
Round Trip or One Way
Round Trip
One Way
Level of Service Needed
Stretcher
Gurney
Wheelchair
Electric Scooter
Ambulatory (able to walk)
Is Oxygen Required?
Yes
No
Are there any personal belonging?
Yes
No
Are there any steps at the pickup or drop off Addresses?
Yes
No
Additional Comments (Notes, Number of Stairs, How many LTR Oxygen, etc.)
SUBMIT
