Medical Transportation Booking Request

Please Note: All bookings must be made 24-Hours prior to pickup time.

Welcome. Please fill out all required fields to submit your transportation request.

Name *

First

Last

Your Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Cell Number *

Email *

Pickup Date / Time *

Date

Time

Time of Appointment *

Destination *

Return Date / Time

Date

Time

Circle One *

• Waiting
• Pick Up / Returning

Comments / Requests

Accepted

• Yes
• No

Driver Name:

Driver Phone:

AMOUNT DUE:

To be collected at pickup. We accept Cash, Credit Cards and Venmo

Submit Transportation Request

PRICING PER TRIP:

Portland and Bangor – $200

Logan – $450

Augusta – $65

Veteran’s Hospital – $75.00

Wait time $75 per hour

We accept Cash, Venmo @Ron-LeClair-3 or credit cards with a fee.

50% deposit required at the time of reservation.

*Cancellation fees may apply day of reservation