Today's Date
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MM
DD
YYYY
Contact Name
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First Name
Last Name
Contact Phone
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(###)
###
####
Contact Email
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About You:
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Choose one
I represent a community or facility.
I am scheduling personal wheelchair transport on behalf of a friend or family member.
I am scheduling wheelchair transport for myself in cooperation with a community or facility.
I am scheduling personal wheelchair transport for myself.
Name of Community or Facility (if applicable)
Client/Passenger Name
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First Name
Last Name
Client/Passenger Phone
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(###)
###
####
Client/Passenger Date of Birth
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MM
DD
YYYY
Transport Date
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MM
DD
YYYY
Type of ride
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One way
Round Trip
Weekend Surcharge
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Yes, weekend $45 surcharge each way
No weekend surcharge
Pickup time
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Pickup Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Room number
Drop Off Facility Name
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Drop off Time
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Appointment time (if applicable)
Drop Off Address (include suite #)
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Does Client have their own wheelchair?
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Yes
No
Type of wheelchair
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If "Yes" indicate type. Note: if you have an electric wheelchair then it must have metal hooks so we can secure it.
Manual wheelchair
Electric wheelchair
Oxygen in use?
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Note: we do not administer nor supply oxygen. It is the patient's responsibility.
Yes
No
Weight Consideration
Is client over 300 pounds?
Yes
No
Leg Extended?
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Yes
No
Ride Along Passenger?
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Yes
No
Behavioral Health Concerns?
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Yes
No
Isolation Concerns?
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Yes
No
Behavioral and/or Isolation concerns:
If "Yes" to behavioral or isolation concerns, please describe.
Return trip needed?
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Yes
No
Special Instructions or concerns
OXYGEN DISCLAIMER
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Please check to acknowledge.
Note: we do not administer or supply oxygen to patient. This is their responsibility.
COVID-19 RELEASE OF LIABILITY
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Check to consent to release of COVID-19 liability
Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), our business is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfecting procedures in compliance with CDC guidance. Symptoms of COVID-19 include fever, dry cough, difficulty breathing. You agree to the following: I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days. I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days. I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days. I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a "hot spot" for COVID-19 infections within the past 30 days. I understand that Door 2 Door Shuttle, LLC cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client. Our business is following these enhanced procedures to prevent the spread of COVID-19: We are in compliance with business wide practices for reducing the risk of COVID-19. By checking the box, I agree to each statement above and release Door 2 Door Shuttle, LLC from any and all liability for unintentional exposure or harm due to COVID-19.
TERMS AND CONDITIONS
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Check to consent to Terms and Conditions.
The prices on our website are estimates only. Additional charges for stops, waiting time, parking, tolls, etc. may apply. Final charges for the trip are determined upon ride completion.
Additional Terms & Conditions may be found on the Door2Door Shuttle website under “Service Terms.”
CANCELLATION POLICY
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Check to consent to our cancellation policy.
Cancellations are accepted by phone only at 972-987-0346. We require that all cancellations be received no less than 48 hours prior to scheduled pickup time. If you have not contacted Door 2 Door Shuttle within the cancellation time frame then you will be charged the full fare. Please note that all cancellations submitted on time are subject to a $35 cancellation fee.