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CONTACT

Geaux Time Rides

FILL OUT THE FORM BELOW

Let's Chat

Phone

504-273-6878

Email

geauxtimerides@gmail.com

Social Media

Client Information

Full Name*

Phone Number*

Email Address

Date of Birth

Month

Day

Year

Are you the passenger

Yes

No (Booking for someone else)

If booking for someone else, your name:

Trip Type

Select Service Type*

Non-Emergency Medical Transportation (NEMT)

Medical Courier

Group Transportation (12-14 Passenger Van)

Select Service Type*

Round Trip

One Way Trip

Appointment Details:

Pick Up Date & Time*

Month

Day

Year

Time

:HoursMinutes

Return Pick Up Time (if round trip)

Time

:HoursMinutes

Pick-Up Address*

Droff-Off Address*

Facility/Location Name (if applicable)

Passenger Needs (Very Important)

Mobility Assistance Required

None

Wheelchair

Walker

Cane

Assistance Entering/Exiting Vehicle

Is the passenger able to transfer independently?

Yes

No

Not Applicable

Number of Passengers

1

2

3+ (Group Transport)

Medical Courier (If Applicable)

Only Complete if booking courier service.

Type of Item(s) being Transported

Documents

Lab Specimen

Medical Supplies

Prescription Pick Up

Pick-Up Location

Delivery Location

Urgency Level

Standard

Same-Day

Stat/Priority

Payment & Insurance

Payment Method

Self-Pay

Medicaid

Facility/Organzation Pay

If Medicaid, Insurance ID Number

Any Special Billing Instructions?

Additional Notes

Special Instructions/Comments

Gate Codes, Caregiver notes, appointment instructions, etc.

Agreement & Submission

I confirmed the information provided is accurate and understand this is a booking request, not a guaranteed reservation.

I authorize Geaux Time Rides to contact me regarding this request.

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