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SCHEDULE A RIDE
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Home
About Us
Services & Fees
Careers
FAQ
Contact
SCHEDULE A RIDE
Schedule a Ride
admin
2023-04-06T13:41:59-07:00
Schedule a Ride
Please enable JavaScript in your browser to complete this form.
1
Rider Info
2
Trip Details
3
Billing, Terms, and Conditions
Who is booking the ride?
*
Transport Coordinator
Family Member
Power of Attortney
The Rider
Other
Have you booked a ride with us before?
*
No
Yes
Your Name
*
First
Last
Email Address
*
Rider Information
Who will we be transporting?
First Name
*
Rider's First Name
Last Name
*
Rider's Last Name
Date of Birth
*
MM
1
2
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4
5
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31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Riders Date of Birth
Rider Phone
*
This is the primary number we'll use for our driver to make contact with the rider for pickup and dropoff questions.
Can this phone receive text messages?
*
Yes
No
Contact Information
What number should we call in the event of traffic problems or locating rider?
*
Use the rider's contact information
Enter separate contact information
Contact Name
*
First
Last
Contact Phone
*
Contact Email
*
Next
Ride Details
Share details about your trip so we can help you get there (and back) on schedule.
Is this a one way or a round trip transportation?
Round Trip
One way
Date of Ride
*
All ride requests must be made at least 72 hours in advance of the trip. If you would like to schedule a ride within the next 72 hours, please call to speak with our scheduling department to be sure there is a space available for your trip.
Appointment Time (rider must be ready 1 hour before appointment time)
*
Pickup Time
*
Patient Mobility Type
*
Ambulatory
Standard Manual Wheelchair
XL Manual Wheelchair
Power Wheelchair
Power Scooter
Walker
Cane
Do you need a wheelchair provided?
*
No
Yes, Standard 16-18 Inch seat
Yes, Extra Large 20-30 Inch seat
*This will incur a fee for each leg of the trip
Patient weight in pounds
*
Patient Height
*
Is this a Hospital or Facility Discharge?
*
Yes
No
Will we be required to go into the hospital or Facility and check/sign you out? and assist with moving personal items? *fee will be incurred for this
Level of care needed
*
Hand to Hand (Do not leave alone)
Door to Door
Curb to Curb (we will call upon arrival)
*We are not and do not provide caregivers, one qualified caregiver can ride with patient at no additional cost.
Does the pickup or drop off location have steps to get in or out of the building?
*
No steps
Only 1 step (Curb or entry to building)
Multiple steps
We can get a wheel chair up or down one step (curb, step up into house). If there are multiple steps together, please call our dispatch line before continuing this ride request.
Additional Passengers or caregivers?
*
No additional passengers
One qualified caregiver
2 total additional passengers
3 total additional passengers
One qualified care giver can ride along at no additional charge, further additional passengers are charged at $15.00 each.
Additional Wait time
Not needed
15 minutes
30 minutes
Please select amount of time that might be needed If you have concern for the patient's readiness at residence or appointment pickup times. *wait time fees will be incurred.
Pickup Address
*
Address Line 1
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Drop Off Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Drop off Suite/Floor/Dr. Name
*
Return Ride
Would you like a return ride?
*
Yes
No
Would you like the driver to wait at the drop off location for your return ride?
*
No, Please return at scheduled return pickup time.
Wait 15 minutes
Wait 30 minutes
Wait 1 hour
Normally we will schedule your return ride on the same or a different driver who drops you off, based on schedule availability. However, if you would like we can have the drive stay at the drop off location and wait for your return trip. *This does incur wait time fees.
Pickup Time (for return)
*
Where will we find you to pick you back up? Suite/Floor/Dr. Name
*
Drop Off Address (for return)
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have a third destination for this trip?
*
NO
YES
Pickup Time (for third destination)
*
Third leg destination address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Previous
Next
Billing Information
Who is paying for this transportation?
*
Private Party
Facility or Broker
Please choose Private Party unless you have already setup a contract with us. (If you are a facility wanting to setup a contract, please contact us at (503) 999-8265)
Facility / Broker name
*
You must have current contract with us, We will use billing information that we already have on file.
Billing Contact Name
*
First
Last
Billing Contact Phone
*
Billing Contact Email
*
Billing Contact Address
*
Address Line 1
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Would you like us to bill a saved credit/debit card?
Yes
No, Please contact me for updated billing info.
If you do not have a card on file with us, you can skip this question.
Comments / Special Needs - Is there anything you'd like us to know to make your trip more comfortable?
*
NOTE: We do not provide oxygen, but can transport if rider has their own portable oxygen tank
How did you find us?
*
Please Select One
Google
Social Media
Word of Mouth
Other
Please explain
*
How did you find us?
Terms and Conditions
When we receive your trip request our scheduling dept will contact you to confirm your trip details. We cannot guarantee that your trip can be scheduled until it is confirmed by our scheduling dept. You may also contact us via email or phone, but keep in mind that we do often experience a high call volume, so please leave a message if we cannot answer your call.
*
I understand that Sovereign Medical must contact me before my trip is confirmed.
Cancellations must be made no less than 24 hours in advance. Last minute cancellations (less than 24 hours) will result in a fee equal to the first pick up fee plus 50% of return (if round trip) When your trip is scheduled we cannot fill that space if it is vacated last minute.
*
I understand and agree to Sovereign Medical's cancellation terms.
A trip is considered a No Show if it is cancelled within 2 hours of the scheduled pickup time, or cancelled at the door when the driver arrives. When your trip is scheduled we cannot fill that space if it is vacated last minute. No Show fees are charged at the full base rate for the A and B leg and mileage for A-leg of the scheduled trip.
*
I understand and agree to Sovereign Medical's cancellation terms.
Any trips that are canceled within a 24 hour period and rebooked for a later date will be subject to a 50 dollar rescheduling fee. When your trip is scheduled we cannot fill that space if it is vacated last minute. (This is only an option if the ride is NOT considered a No-show)
*
I understand and agree to Sovereign Medical's cancellation terms.
All refunds are subject to a $10 refund processing fee.
*
I understand and agree to Sovereign Medical's cancellation terms.
Payments must be made in advance (must be paid by 5PM the day before the trip) once trip is confirmed. Please note applicable cancellation/no show policies listed above. Alternate payment arrangements may be possible for ongoing recurring trips.
*
I understand that payment arrangements will be made after my trip is confirmed.
Any additional services incurred during transport or at the time of pickup will be immediately invoiced and/or charged to the billing contact provided at time of booking. This includes but is not limited to: Standby / Wait fees, Provide wheelchair fees, Hospital/Facility discharge fees, and Additional passenger fees. A list of our current fees can be found at https://www.sovmedical.com/services-fees/
*
I understand and agree to Sovereign Medical's additional fees policy.
Name
Submit Ride Request
Schedule a Ride
Please enable JavaScript in your browser to complete this form.
1
Rider Info
2
Trip Details
3
Billing, Terms, and Conditions
Who is booking the ride?
*
Transport Coordinator
Family Member
Power of Attortney
The Rider
Other
Have you booked a ride with us before?
*
No
Yes
Your Name
*
First
Last
Email Address
*
Rider Information
Who will we be transporting?
First Name
*
Rider's First Name
Last Name
*
Rider's Last Name
Date of Birth
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Riders Date of Birth
Rider Phone
*
This is the primary number we'll use for our driver to make contact with the rider for pickup and dropoff questions.
Can this phone receive text messages?
*
Yes
No
Contact Information
What number should we call in the event of traffic problems or locating rider?
*
Use the rider's contact information
Enter separate contact information
Contact Name
*
First
Last
Contact Phone
*
Contact Email
*
Next
Ride Details
Share details about your trip so we can help you get there (and back) on schedule.
Is this a one way or a round trip transportation?
Round Trip
One way
Date of Ride
*
All ride requests must be made at least 72 hours in advance of the trip. If you would like to schedule a ride within the next 72 hours, please call to speak with our scheduling department to be sure there is a space available for your trip.
Appointment Time (rider must be ready 1 hour before appointment time)
*
Pickup Time
*
Patient Mobility Type
*
Ambulatory
Standard Manual Wheelchair
XL Manual Wheelchair
Power Wheelchair
Power Scooter
Walker
Cane
Do you need a wheelchair provided?
*
No
Yes, Standard 16-18 Inch seat
Yes, Extra Large 20-30 Inch seat
*This will incur a fee for each leg of the trip
Patient weight in pounds
*
Patient Height
*
Is this a Hospital or Facility Discharge?
*
Yes
No
Will we be required to go into the hospital or Facility and check/sign you out? and assist with moving personal items? *fee will be incurred for this
Level of care needed
*
Hand to Hand (Do not leave alone)
Door to Door
Curb to Curb (we will call upon arrival)
*We are not and do not provide caregivers, one qualified caregiver can ride with patient at no additional cost.
Does the pickup or drop off location have steps to get in or out of the building?
*
No steps
Only 1 step (Curb or entry to building)
Multiple steps
We can get a wheel chair up or down one step (curb, step up into house). If there are multiple steps together, please call our dispatch line before continuing this ride request.
Additional Passengers or caregivers?
*
No additional passengers
One qualified caregiver
2 total additional passengers
3 total additional passengers
One qualified care giver can ride along at no additional charge, further additional passengers are charged at $15.00 each.
Additional Wait time
Not needed
15 minutes
30 minutes
Please select amount of time that might be needed If you have concern for the patient's readiness at residence or appointment pickup times. *wait time fees will be incurred.
Pickup Address
*
Address Line 1
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Drop Off Address
*
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Drop off Suite/Floor/Dr. Name
*
Return Ride
Would you like a return ride?
*
Yes
No
Would you like the driver to wait at the drop off location for your return ride?
*
No, Please return at scheduled return pickup time.
Wait 15 minutes
Wait 30 minutes
Wait 1 hour
Normally we will schedule your return ride on the same or a different driver who drops you off, based on schedule availability. However, if you would like we can have the drive stay at the drop off location and wait for your return trip. *This does incur wait time fees.
Pickup Time (for return)
*
Where will we find you to pick you back up? Suite/Floor/Dr. Name
*
Drop Off Address (for return)
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you have a third destination for this trip?
*
NO
YES
Pickup Time (for third destination)
*
Third leg destination address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Previous
Next
Billing Information
Who is paying for this transportation?
*
Private Party
Facility or Broker
Please choose Private Party unless you have already setup a contract with us. (If you are a facility wanting to setup a contract, please contact us at (503) 999-8265)
Facility / Broker name
*
You must have current contract with us, We will use billing information that we already have on file.
Billing Contact Name
*
First
Last
Billing Contact Phone
*
Billing Contact Email
*
Billing Contact Address
*
Address Line 1
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Would you like us to bill a saved credit/debit card?
Yes
No, Please contact me for updated billing info.
If you do not have a card on file with us, you can skip this question.
Comments / Special Needs - Is there anything you'd like us to know to make your trip more comfortable?
*
NOTE: We do not provide oxygen, but can transport if rider has their own portable oxygen tank
How did you find us?
*
Please Select One
Google
Social Media
Word of Mouth
Other
Please explain
*
How did you find us?
Terms and Conditions
When we receive your trip request our scheduling dept will contact you to confirm your trip details. We cannot guarantee that your trip can be scheduled until it is confirmed by our scheduling dept. You may also contact us via email or phone, but keep in mind that we do often experience a high call volume, so please leave a message if we cannot answer your call.
*
I understand that Sovereign Medical must contact me before my trip is confirmed.
Cancellations must be made no less than 24 hours in advance. Last minute cancellations (less than 24 hours) will result in a fee equal to the first pick up fee plus 50% of return (if round trip) When your trip is scheduled we cannot fill that space if it is vacated last minute.
*
I understand and agree to Sovereign Medical's cancellation terms.
A trip is considered a No Show if it is cancelled within 2 hours of the scheduled pickup time, or cancelled at the door when the driver arrives. When your trip is scheduled we cannot fill that space if it is vacated last minute. No Show fees are charged at the full base rate for the A and B leg and mileage for A-leg of the scheduled trip.
*
I understand and agree to Sovereign Medical's cancellation terms.
Any trips that are canceled within a 24 hour period and rebooked for a later date will be subject to a 50 dollar rescheduling fee. When your trip is scheduled we cannot fill that space if it is vacated last minute. (This is only an option if the ride is NOT considered a No-show)
*
I understand and agree to Sovereign Medical's cancellation terms.
All refunds are subject to a $10 refund processing fee.
*
I understand and agree to Sovereign Medical's cancellation terms.
Payments must be made in advance (must be paid by 5PM the day before the trip) once trip is confirmed. Please note applicable cancellation/no show policies listed above. Alternate payment arrangements may be possible for ongoing recurring trips.
*
I understand that payment arrangements will be made after my trip is confirmed.
Any additional services incurred during transport or at the time of pickup will be immediately invoiced and/or charged to the billing contact provided at time of booking. This includes but is not limited to: Standby / Wait fees, Provide wheelchair fees, Hospital/Facility discharge fees, and Additional passenger fees. A list of our current fees can be found at https://www.sovmedical.com/services-fees/
*
I understand and agree to Sovereign Medical's additional fees policy.
Message
Submit Ride Request
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