Schedule a Ride

Username or Email *

Password *

Remember me

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1Rider Info

2Trip Details

3Billing, Terms, and Conditions

Who is booking the ride? *

Have you booked a ride with us before? *

Your Name *

First

Last

Email Address *

Note: this email address will be used for new user registration and/or future sign-ins to easily pre-fill responses for this form.

Rider Information

Who will we be transporting?

First Name *

Rider's First Name

Last Name *

Rider's Last Name

Date of Birth *//

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? *

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 *

Save and Resume Later

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 *

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? *

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

Zip Code

Drop Off Address *

Address Line 1

City

State

Zip Code

Drop off Suite/Floor/Dr. Name *

Return Ride

Would you like a return ride? *

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

State

Zip Code

Do you have a third destination for this trip? *

Pickup Time (for third destination) *

Third leg destination address *

Address Line 1

Address Line 2

City

State

Zip Code

Save and Resume Later

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

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 explain *

How did you find us?

Terms and Conditions

We must be notified at time of booking or up to 24 hours before scheduled pickup time of any rider that is suspected or known to be COVID-19 Positive. *

I understand and agree to Sovereign Medical's scheduling conditions.

Trips must be requested no less than 72 hours in advance and cannot be guaranteed until we can confirm the trip fits in our schedule. More immediate needs may be scheduled by phone only, and depends upon schedule availability. Please be aware that our schedule fills quickly. We will always do our very best to serve you! *

I understand and agree to Sovereign Medical's scheduling 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). No shows will be billed at full current pick up rates for both legs of the trip. 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. *

I understand and agree to Sovereign Medical's cancellation terms.

Payment arrangements must be made in advance once trip is confirmed. Please note applicable cancellation/no show policies listed above. Credit Card Processing Fee: 5% of total transaction is Non-Refundable and is applied to charge and refund transactions *

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 in this form. This includes but is not limited to: Standby / Wait fees, Provide wheelchair fees, Hospital/Facility discharge fees, and Additional passenger fees. *

I understand and agree to Sovereign Medical's additional fees policy.

Name

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Schedule a Ride

Returning Client Sign In

(Ignore if this is your first time here)

Username or Email *

Password *

Remember me

Remember me

1Rider Info

2Trip Details

3Billing, Terms, and Conditions

Who is booking the ride? *

Have you booked a ride with us before? *

Your Name *

First

Last

Email Address *

Note: this email address will be used for new user registration and/or future sign-ins to easily pre-fill responses for this form.

Rider Information

Who will we be transporting?

First Name *

Rider's First Name

Last Name *

Rider's Last Name

Date of Birth *//

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? *

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 *

Save and Resume Later

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 *

Appointment Time (rider must be ready 1 hour before appointment time) *

Pickup Time *

Patient Mobility Type *

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? *

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

Zip Code

Drop Off Address *

Address Line 1

City

State

Zip Code

Drop off Suite/Floor/Dr. Name *

Return Ride

Would you like a return ride? *

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

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

State

Zip Code

Do you have a third destination for this trip? *

Pickup Time (for third destination) *

Third leg destination address *

Address Line 1

Address Line 2

City

State

Zip Code

Save and Resume Later

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

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 explain *

How did you find us?

Terms and Conditions

We must be notified at time of booking or up to 24 hours before scheduled pickup time of any rider that is suspected or known to be COVID-19 Positive. *

I understand and agree to Sovereign Medical's scheduling conditions.

I understand and agree to Sovereign Medical's scheduling conditions.

I understand that Sovereign Medical must contact me before my trip is confirmed.

I understand and agree to Sovereign Medical's cancellation terms.

I understand that payment arrangements will be made after my trip is confirmed.

I understand and agree to Sovereign Medical's additional fees policy.

Comment

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternatively, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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