WheelCare Transportation

WheelCare Transportation
Lubbock, TX 79413
ph: 806-794-7573
fax: 1-800-261-4272
wheelcaretransportation@yahoo.com

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We have added this page in an attempt to make it even easier for our customers to schedule appointments.

This form should be used ONLY to set up appointments that are being made in advance. If you need immediate (within 24 hours) or after-hours transportation, we ask that you contact us at
806-794-7573.

(After-hours transportation includes rides between 7pm and 7am. )

After you submit the appointment form below we will contact you to confirm.

Transportation has not been scheduled unless you receieve confirmation.

Appointment Form- WheelCare Transportation

*Service Requested:

Please select one of the trips from the drop-down menu. If you need a service other than what is listed, please specify in the "Additional Service Instructions" area at the bottom of the form.

*Passenger's Full Name:

*Date of Service:

*Appointment Time:

*PLEASE BE READY 45-60 MINUTES IN ADVANCE OF YOUR APPOINTMENT TIME FOR ALL LUBBOCK RIDES*

*Pick-Up Location:

Please enter the name of the business (if applicable) and the address of the location where the passenger is to be picked up. If you are scheduling a Round Trip than the passenger will be returned to this address.

*Passenger's Destination:

Please enter the address of the location where we will be taking the passenger.

*The passenger is:

In a standard sized wheelchair In a Large wheelchair (Additional Fee) Ambulatory (Walker) Other

*If you chose other, please describe in the "Additional Service Instructions" area below

Passenger Needs:

Oxygen (Free) Standard Wheelchair (Free) Large Wheelchair (Additional Fee) Gerry Chair (Additional Fee) Reclining Back Wheelchair (Additional Fee)

Checking an option above means that you wish for WheelCare to provide this item for the patient at the time of service. You may select more than one. If NO items are selected than it will be assumed that the patient will provide their own wheelchair.

Additional Service Instructions:

Please add any other information that we may need to know before transporting the passenger.

*Appointment Scheduled By:

Please enter your name.

*Phone:

We will call you to confirm the appointment.

Email:

*Payment:

Credit Card (At Time of Ride) Cash (At Time of Ride) Check (At Time of Ride) Bill Me

Because service provided varies by passenger, you will be quoted a price when we call to confirm.

Bill To:

If we are billing you for your transportation, please enter your billing info above.

Submit Your Message:

Thank you for your business.

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WheelCare Transportation
Lubbock, TX 79413
ph: 806-794-7573
fax: 1-800-261-4272
wheelcaretransportation@yahoo.com

Friend us: