Facility Appointment Request

To schedule transportation for your patient(s), please fill out the appointment request below. You will receive an email confirmation within 12 hours after submitting the request.

You may also call us with questions or requests at 864.561.6444 or send email to contact@1sttransportationgroup.com.

Name of Person Completing Form *

Email Address *

Facility Name *

Phone Number *

Facility / Pick Up Address *

Is this Facility responsible for transportation payment? *

Yes

No

If "No," please indicate who is responsible for payment.

Patient/Client Full Name *

Patient/Client Full Name

First

Last

Level of Service *

Ambulatory

Wheelchair

Stretcher

None

Oxygen Needed? *

Yes

No

Any Restrictions?

Date of Birth *

Approximate Weight (lbs) *

Room Number

Appointment Type

Appointment Date *

Appointment Time *

Appointment Address/Location *

Location Phone Number

Is patient being returned to Facility after this appointment? *

Yes

No

** 1st Transportation Group usually schedules pickup one hour before appointment time. **

Additional Information (optional)

If you are human, leave this field blank.

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