TLC Mobility Transport Services

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

Passenger profile Returning passengers may skip saved details only if TLC already has them and they are unchanged.

New Passenger Returning Passenger

Who is requesting this ride?

Passenger (myself) Facility Family member or friend

Name of person booking this ride

First and last name of the person submitting this request.

Relationship to passenger / facility role

Booking contact phone number

Best number to reach the person arranging this ride.

Reply email for secure confirmation

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

About the Passenger

Passenger full name

First and last name

Passenger phone number

Required if booking your own ride; otherwise, provide the passenger’s number if available.

Date of birth

Weight (lb)

Height (ft / in)

Assistance Needed

Type of transfer

Self / Independent Ambulatory: Short Distances Standby Assist One-Person Assist Two-Person Assist Stand-Pivot Hoyer

Wheelchair Type: Select all that apply. Wheelchairs must have footrests during transport. TLC cannot transport passengers seated in transport chairs with four small wheels.

None Needed: Client is Ambulatory

Standard wheelchair

Motorized wheelchair

Bariatric wheelchair

Reclining wheelchair

Transport wheelchair (TLC Restricted Chair)

(4) Small Wheels Unable to Transport

Stretcher (Not Available)

Medical and Cognitive Needs

Will the passenger use oxygen during the ride?

No Yes

TLC Does NOT provide Oxygen (Oxygen is to be provided by client)

Oxygen flow (liters per minute)

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

Explain Above Selections / Note any Missing Details

Describe the device or concern and how it affects transportation.

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

Mild

Rider Required

Moderate

Rider Required

Severe

Rider Required

Unsure

Details Required PRIOR to Transport

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 the passenger need an aide or companion during transport?

No companion needed Yes — family or personal caregiver will accompany Yes — facility will provide an aide Yes — TLC Companion Care requested

TLC Companion Care is subject to availability and confirmation. Companions provide supervision and support; TLC does not provide hands-on personal or medical care.

Emergency contact full name (not facility name)

Enter a person’s 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 email

Payment contact phone number

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)

TLC Assistance / Equipment Requested Equipment and assistance are subject to TLC availability and confirmation.

TLC Companion Care Requested

TLC Provides Standard Wheelchair

TLC Provides Bariatric Wheelchair

TLC Provides Reclining Wheelchair

TLC Provides Ramp

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

No Ramp Needed

TLC Ramp Requested

Picture of Entrance Requested

Permanent Ramp

Portable Ramp

Ramp / Entrance Location

Front

Side

Rear

Garage

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

***Photo Request to be sent to care@tlcmobilitynow.com

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 facility / hospital / medical office name

Destination room / suite / building / floor

Enter details if applicable; otherwise enter N/A.

Doctor / provider name

First and last name, or provider / clinic name

Doctor / office phone number

Reason for appointment

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

Input details below

Other appointment reason

Please send any additional information that would be helpful for our transport drivers.

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.