Request a Ride Request a Ride Name * First Name Last Name Birthdate * MM DD YYYY Gender Male Female Email Phone * (###) ### #### Payor (If different from name above) * Mobility Type * Wheelchair Ambulatory Walker Date of Trip * MM DD YYYY Pick Up Time * Hour Minute Second AM PM Appointment Time * Hour Minute Second AM PM One-Way or Round Trip One-way Round Trip Pick Up Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Pick Up Notes Drop Off Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Drop Off Notes How many additional Riders? Additional Rider Name (1) First Name Last Name Additional Rider Name (2) First Name Last Name Additional Information Thank you for your request! You can expect a call from our home office to confirm your appointment. If you do not hear from us, please give us a call at (251) 338-9521. WheelCare will contact you for payment information once we confirm the trip is booked. “You make me smile when I don’t feel like smiling.”— WheelCare Patient It is our pleasure to serve you. Get in touch.
