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1
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Service For
2
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Rider
3
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Pickup
4
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Type of Service
5
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Drop Off
Service For
Individual Self Pay
Hospital or medical industry Facility
Hospital:
ALF Silver Palm
ALF Treasure Isle Care Center
Americas Tours, Inc
AVENTURA HOSPITAL
Baptist
BAPTIST HEALTH HOSPITAL DORAL
Baptist Homestead
Baptist South Miami Hospital
Coral Gables Hospital
Crystal Health & Rehab
Doctors
ENCOMPASS HEALTH REHABILITATION HOSP OF MIAMI
Florida Medical Center (FMC)
HCA FLORIDA UNIVERSITY HOSPITAL
Hialeah Hospital
Kendall Regional Medical Center
KERALTY HOSPITAL
Larkin Community Hospital
LARKIN PALM SPRINGS
Mercy Hospital
North Shore Medical Center
PALMETTO CARE CENTER
Palmetto General Hospital
West Kendall Baptist Hospital
Rider
First Name*:
Last Name*:
Date Of Birth*:
Email*:
Phone Number*:
Pickup
Building name:
Address*:
Room # or Suite #:
Pickup Date*:
Pick up time*:
Hour:
00
01
02
03
04
05
06
07
08
09
10
11
12
Minute:
00
05
10
15
20
25
30
35
40
45
50
55
am
pm
Type of Service
Type of mobility:
AMBULATORY
WHEELCHAIR
STRETCHER
Services:
STAIR CHAIR LIFT
BARIATRIC (More than 240 pounds)
Weight (pounds):
Legs:
ONE WAY
ROUNDTRIP
Notes:
Drop Off
Building name:
Address*:
Room # or Suite #:
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