Facility Booking To schedule transportation, please complete the form below, and we’ll promptly contact you for confirmation. Facility Booking Facility Contact Information Facility Name * Facility Contact * Facility Contact First Name First Name Last Name Last Name Facility Contact Phone (Used for Confirmations) * Facility Contact Email (Used for Confirmations) * Booking Information One way or Round trip? * One way Round trip Pickup Location (Please Include Unit, if applicable) * Drop off Address * Floor/Suite/Department Specialty (if applicable) Pickup Date * Pickup Time * Appointment Time * Estimated Return Pickup * Patient's First Name * Patient's Last Name * Additional Notes/Instructions (if applicable) Billing information * Facility pay Patient pays Payer's Full Name? Payer's Email Payer's Phone Number Transport by (Please select from drop down) * Ambulatory (Wheelchair/Gurney Not Required)Bariatric/Power chair (Over 200lbs including chair)Standard Wheelchair (up to 200lbs including chair) I confirm that all booking information submitted is accurate and complete. I further understand that any same day cancellations will be subject to a cancellation fee. * I Agree I understand that Baker's Transit exclusively accepts Facility and Private Pay and does not participate in any insurance programs * I Agree Request Booking If you are human, leave this field blank. Contact Us Today to Learn More About How We Can Provide the Best Care for Your Loved Ones. Get In Touch
