USER NAME:
PASSWORD:
WCT : Request For Wheelchair Taxi Services
Non-Emergency Medical Transportation
Online Booking
Booking Type:
ROUND TRIP
SINGLE TRIP
*Client's Name:
*Phone Number:
Room Number:
Level:
Department:
*Pick up Address:
Drop Off Address:
*Pick up Time:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Return Time:
01
02
03
04
05
06
07
08
09
10
11
12
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
Organization Information
Organization Name:
*Authorized Person’s Name:
*Address:
*Client’s ID/Claim:
*Adjuster/Case Worker’s Name:
*Phone Number:
*Email address:
Enter details of request:
(Number of appointments
per week, Expected duration
of treatment, days / months,
contract details)
Trip Purpose
Physical Therapy
Fracture Clinic
Dialysis
Medical appointment
Chemotherapy
Behavioral Health
Other (Describe):
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Webmaster:
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