Non-Emergency Medical Transportation

*This form must be submitted 24 Hours in advance of the appointment for a quote and to be scheduled*

Please fill out the form completely. Please note that an extra attendant (two-man) is required if the customer weighs more than 180lbs or if there are more than two stairs involved.

TRIP INFORMATION

TRANSPORTATION DETAILS

DOCTOR/PCP INFORMATION

* Allow a minimum of 45 minutes between pick-up time and appointment time.

PATIENT INFORMATION

First Time Using MTS?

PICK UP ADDRESS

DESTINATION ADDRESS

IMPORTANT: CANCELATION POLICY

Passengers are encouraged to cancel scheduled rides at least 24 hours in advance if possible.
Any cancellation received later than 24 hours prior to the scheduled pick-up will be considered a late cancellation

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