Quality Transport Services - Phoenix, Arizona Ambulatory Transportation Company

Patient Name:		# Additional Riders:
DOB:		Weight:	lbs
One Way Wait and Return Round Trip

Transport Date:		Appointment Time:
Pick Up Time:		Return Time:
		or Will Call:

Level of Service:	Ambulatory Wheelchair Wheelchair/Provided Double Wheelchair Electric Wheelchair Stretcher Double Stretcher Bariatric (300lbs)

Oxygen:	Yes No If yes, how many liters?

Pick-Up Address:
Room/Suite/Lot:		Phone #:
Stairs:	Yes No

Drop-Off Address:
Room/Suite/Lot:		Phone#:
Stairs:	Yes No
Comments:

Billing Information:	To Be Billed Private Pay/Cash/Check Credit Card
Responsible Party:
Phone:
Billing Address:
Credit Card #:
Exp:		Sec. Code:

Name of Person/Facility Placing Order:
To receive an immediate confirmation back from QTS, please indicate how you would like to be contacted:
	Phone:
	Fax:
	E-mail:

HIPAA Disclosure: Information and personal contact information you enter on this form will be securely transmitted directly to QTS and will be kept confidential to the extent required by HIPAA. By submitting your email address with your concern, you consent to communication about your concern by email from QTS. If you do not consent to email communications about your concern, please state your preferred method of communication in the comments section of this form.