REQUEST-A-RIDE PASSENGER INFORMATION Name * First Name Last Name Date Services Desired * MM DD YYYY Appointment Time * Hour Minute Second AM PM Do You Require a Wheelchair for Mobility? * Yes No Size of Your Wheelchair * If you selected "Yes" for a wheelchair, please indicate the size of your wheelchair. Standard Wheelchair Bariatric Wheelchair Geri Chair Mobility Scooter Electric Wheelchair N/A Type of Government-Issued ID Drivers are required to confirm passengers' identity prior to services being rendered. Please select the Government-Issued ID you will show driver. Additionally, you may email a copy in advance of transportation services to administrator@LetUsDriveNC.com or text (833) 538-8737. Driver's License U.S. Passport U.S. Military or Dependent ID Other Government-Issued ID Preferred Phone * (###) ### #### Email * Pick Up Address Address 1 Address 2 City State/Province Zip/Postal Code Country Drop Off Location * Drop Off Address Address 1 Address 2 City State/Province Zip/Postal Code Country Pick Up Time * Hour Minute Second AM PM Drop Off Time * Hour Minute Second AM PM Message Please provide any additional information you deem relevant. Responsible Party at Facility * If you are a facility, please check the appropriate box below to indicate who is responsible for submitting payment. If you are not a facility, please select N/A. Facility Pay - Current Residents Facility Pay - New Admits Private Pay N/A OUR EXPECTATIONS With an emphasis on professionalism and safety, we take pride in exceeding the transportation needs of our passengers. To ensure our relationship is mutually beneficial, we have the following expectations: * Please check each box to confirm you have read, understand and agree to comply with our expectations. Payment is expected in advance of services. Payment is is accepted electronically via the web or telephone. Cash is not accepted. In the event that prior authorization is granted to pay with cash, please ensure that you have the exact amount as change will not be provided. Once payment is submitted, no refund will be given. Please be advised if an appointment is canceled after payment has been submitted, or if the client is a no-show, the client will be assessed a no-show/cancellation fee ranging from $25 to $50, depending on the the level of mobility (e.g., ambulatory, wheelchair). If the appointment is rescheduled, the client may be required to pay any difference in cost based on updated trip details or mobility classification. Be respectful to the driver and other passengers. Additionally refrain from using profane language. During a pandemic, drivers and passengers are expected to wear a mask over their nose and mouth. Failure to do so will result in services not being rendered and clients will be assessed a cancellation fee ranging from $25-$50, depending on the level of mobility ( e.g., ambulatory, wheelchair) for the investment of our time. If wait time is desired, an additional charge of $40 per hour or $10 every 15 minutes will be charged. YOUR RESPONSIBILITIES In an effort to ensure that both driver and passenger have the best experience possible, we ask that you adhere to the following ground rules: * Please check each box to confirm that you have read, understand and agree to comply with the outlined responsibilities. Enter the vehicle immediately upon arrival. Do not bring alcohol, drugs or weapons in the vehicle. Do not smoke, eat or drink in the vehicle. Always wear your seat belt while traveling in the vehicle. YOUR SIGNATURE By typing your name below and checking the boxes below, you acknowledge you have read, understand and agree to comply with the terms of this agreement. * I have read and understand the terms of this agreement. I agree to comply with the terms of this agreement. I understand that if I fail to comply with the terms of this agreement, I will not hold Emmanuel Medical Transport Corp. liable and I understand that Emmanuel Medical Transport Corp. reserves the right to discontinue my transportation services at any time without advanced notice. Full Name * First Name Last Name Today's Date * MM DD YYYY Thank you for your message. We will be in contact with you as soon as possible.
