Injury Care Emergency Medical Services
Call 24/7
208-914-3846
/
855-492-9941
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Request a Quote
Use this form to request a quote for any of our non-emergency services. If this is an urgent request, please call our dispatch at 208-914-3846.
Step 1 of 2
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Purpose of Quote
*
What are you requesting a quote for?
Transportation (not urgent)
Event Medical Support
Use this form for non-urgent transportation requests ONLY. We will respond within 24 hours. For urgent requests, please call our dispatcher 208-914-3846.
NOTE: For payment purposes you must fax Ins/MA paperwork to 208-375-1196 in order for us to set up your transportation request.
Passenger Name
*
First
Last
Individual or Company?
*
Are you requesting transportation for yourself or on behalf of a company or institution?
Individual
Company
Name of Company
*
Company Contact Name
*
Contact Phone
*
Fax Number
Contact Email
*
Date Transportation is needed
*
Date Format: MM slash DD slash YYYY
Date Transportation is needed
Date Format: MM slash DD slash YYYY
Date Transportation is needed
Date Format: MM slash DD slash YYYY
Event Venue
*
Venue Address
*
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Billing Address
*
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Date of Event
*
Date Format: MM slash DD slash YYYY
Date of Event
Date Format: MM slash DD slash YYYY
Date of Event
Date Format: MM slash DD slash YYYY
What Time(s) is the event
*
Event Description
*
Briefly state what the event is (i.e., a concert, sports event)
Is this event for a charity or a 501(c)(3)?
*
Yes
No
Name of Charity
Special Requirements or Information we need to know
Round Trip or One Way?
*
Wait for return (round trip)
One way
Pickup Location Name
*
i.e., home, Willow Park Sr. Living, etc.
Pickup Address
*
Please enter 9 digit zip (
look up here
)
Street Address
City
ZIP Code
Destination Name
*
For example, St. Luke's Clinic.
Destination Address
*
Please enter 9 digit zip (
look up here
)
Street Address
City
ZIP Code
Do you need transportation for a wheelchair?
*
Yes
No
Do you need gurney transportation?
*
Yes
No
Medical equipment or supplies required
For example: oxygen, ventilator, cardiac monitor, IV, etc.
How will this trip be paid for?
*
Private pay (cash or check)
Credit Card
Commercial Insurance
Medicare
Date of Birth
*
If using medical assistance, please enter the insured's date of birth.
Date Format: MM slash DD slash YYYY
Credit card info
*
If paying by credit card, please enter name of the person to call to provide credit card information.
Address
*
If paying by cash or check, please enter payee's address.
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Message
Any further information we need to know?
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