TLC Mobility Transport Services

If this is an emergency, call 911. TLC Mobility Transport Services is a non-emergency ambulette company.

About the Passenger

Passenger full name

First and last name

Who is requesting this ride?

Passenger (myself) Facility Family member or friend

Passenger profile Skip saved DOB, height, emergency contact, and payment contact details only if TLC Mobility Transport Services already has them and they are unchanged. Use the passenger name above to match our records.

New Passenger Returning Passenger

Facility contact name

First and last name

Facility name

Reply email for secure confirmation

Use the email of the passenger or the person arranging this ride.

Family member / friend name

First and last name

Relationship to passenger

Facility contact position

Contact phone number

Date of birth

Height (ft / in)

Passenger phone number

Provide a contact number when requesting your own ride; otherwise optional if the passenger has a phone.

Assistance Needed

Type of transfer

Self Walks with Assistance Aide Stand and Pivot Hoyer

Weight (lb)

Wheelchair type Select all that apply if a wheelchair will be used. TLC Mobility Transport Services does not transport passengers in transport chairs with four small wheels.

Standard wheelchair

Motorized wheelchair

Bariatric wheelchair

Reclining wheelchair

Medical and Cognitive Needs

Does the passenger have medical devices, health conditions, or cognitive concerns that may affect the ride? Examples include a Foley catheter, trach, feeding / PEG tube, memory or behavior concerns, and infection precautions.

No Yes

Will the passenger use oxygen during the ride?

No Yes

Oxygen flow (liters per minute)

Enter the prescribed flow in liters per minute (for example, 2 or 2.5).

Cognitive impairment level Describe the passenger’s current level as reported by the passenger or caregiver.

Mild Moderate Severe Unsure

Other medical device / condition details

Describe the device or concern and how it affects transportation.

Transport-related care instructions / other concerns

Include other conditions and any required infection / isolation precautions (for example, COVID-19, flu, C. difficile, or MRSA) that affect transportation.

Hoyer transfer arrangements (if applicable)

Who provides the lift and performs the transfer at pickup and destination? TLC will confirm arrangements.

Will an aide or companion accompany the passenger?

No Yes

Emergency contact full name

First and last name

Emergency contact relationship to passenger

Emergency contact phone number

Payment

Who is paying for the ride?

Self-Pay Bill Facility

Responsible payer / facility name

Payment contact full name

First and last name

Payment contact phone number

Payment contact email

Ride Date and Time

Requested ride date

Trip type

One-way Roundtrip

Appointment time (include AM or PM)

TLC Mobility Transport Services will decide and confirm the scheduled pickup time.

Expected appointment duration (for roundtrip requests)

Pickup

Pickup location type

Home Facility Hospital Medical Office

Pickup full address

Include street address, city, state, and ZIP code.

Pickup facility / hospital / medical office name

Pickup room / unit / suite / building / floor

Home ramp availability

Permanent ramp

Portable ramp

No ramp

Ramp / entrance location

Front

Side

Rear

Garage

Stairs / steps at pickup (number of steps or none)

Pickup and entry instructions

Destination

Drop-off location type

Home Facility Hospital Medical Office

Destination full address

Include street address, city, state, and ZIP code.

Destination building / suite / floor

Doctor / provider name

First and last name, or provider / clinic name

Doctor / office phone number

Reason for appointment

Follow-up visit Scan / imaging Lab work / testing Therapy / rehabilitation Dialysis Treatment / procedure Consultation / routine visit Other

Other appointment reason

Assistance / equipment requested Equipment and assistance are subject to TLC Mobility Transport Services confirmation.

TLC to bring a wheelchair

TLC to bring a portable ramp

Additional assistance needed

No additional equipment needed

Describe additional assistance or equipment needs

Before you submit

This is a ride request. Your ride is confirmed only after TLC Mobility Transport Services accepts it and confirms the scheduled pickup time. Equipment, transfer arrangements, and assistance are subject to confirmation.

Submit only information needed for transportation and only if you are the passenger or authorized to make this request. Please use secure replies for passenger information.

Privacy and Security

Information submitted through this form is encrypted by Hushmail. Hushmail’s secure forms are designed to support HIPAA compliance, with a Business Associate Agreement (BAA) available.

Please share only information needed for transportation. Use this secure form or secure replies for passenger information.

Your information will be encrypted.