Request Quote - AMBULANCE USA

REQUEST A QUOTE

We’re here for you and can schedule a transport 24 hours a day, 7 days a week.

Request For Quote Main

All transports are based on availability; the more notice is provided, the better. We suggest at least 24-48hrs in advance if possible. If your transport is needed in less than 24hrs., please call our dispatch office to provide your details and check for availability.

Contact Information

First Name *

Last Name *

Company

Title

Phone *

Ex. +1 (999) 999-9999

Mobile

Ex. +1 (999) 999-9999

Fax or other

Ex. +1 (999) 999-9999

Email *

Preferred method of contact

Your Reference#

Transport Information

Transport Date *

Pick Up Time *

Appointment Time

Patient Returning? *

If Returning, shall crew wait with the Patient? *

Type of Transport *

Type of Transport

Air Ambulance/Medical Escort related? *

Is transport needed at origin & destination cities? *

Aircraft tail/flight #

Is the tail # trackable?

Flight medical team transportation needs: *

Section

Departure Airport Code *

Departure Date *

Departure Time *

Arrival Airport Code *

Arrival Date *

Arrival Time *

Section

Level of medical transport requested *

Cot size *

Medical details & equipment needed for transport *

Pick-up Origin

Pick-up origin (Name and Address) *

City *

State or Province

Zip Code

Country

Drop-off Origin

Drop-off origin (Name and Address) *

City *

State or Province

Zip Code

Country

Pick-up Destination

Pick-up destination (Name and Address) *

City *

State or Province

Zip Code

Country

Drop-off Destination

Drop-off destination (Name and Address) *

City *

State or Province

Zip Code

Country

Special instructions or important notes

For Wheelchair Van transports; Specify if the patient has his own wheelchair or if he needs one for transport.

Upload related documentation

Relevant to your transport request, the following current documentation is recommended (if available):
• Latest Patient’s Medical Report or History and Physical
• Latest Flight Itinerary (if related to air transportation)
• Latest Test Results including COVID-19
• Memorandum of Transport or Latest Discharge Progress Notes
• Out of Hospital Do Not Resuscitate Order (if applicable)
• Any Other Relevant Documentation

Maximum upload size: 5MB

Each trip is booked as per availability upon signed contract, payment or credit card preauthorization are received.

Upon receiving your complete schedule request, a medical transportation specialist will check availability and will get back with you with a confirmation number once your transport is booked.

If you are human, leave this field blank.