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Transportation Reservation Request

1. Enter client's name
 
2. Enter the address/location for the pick up request
Street Address (include unit/apt no. as it applies)
 
City
 
State

Florida

Zip Code
 
Home Phone
 
Mobile Phone
 
Date of Appointment
 
Time of Appointment
 
Time of Return
 
3. Destination
Please provide us with the name of the facility you are traveling to
 
Facility Street Address
 
City
 
State

Florida

Zip Code
 
Facility Phone
 
Doctor's Name
 
4. Medical Reason for Appointment. Please be specific; some funding will not transport without this information
 
5. Escort Needed


6. Options


*Please justify stretcher request with a medical reason
7. Contact Person or Person Submitting Request
Name
 
Phone
 
Email
 
Fax
 




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We enhance the quality of life for people throughout Polk County
Polk County Board of County Commissioners | 330 West Church Street | P.O. Box 9005 | Bartow, FL 33830 | 863.534.6000