Monroe Ambulance / Transportation - Rochester NY

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Emergency Transport
(585) 232-9000

Non-Emergency Transport
(585) 454-6211

Billing / Collections
(585) 454-6215

Medical Records
(585) 327-7652

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April 20, 2010
Monroe's TV commercial shot at Frontier Field.  - read more -

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NON-EMERGENCY TRANSPORTATION REQUEST FORM
*This form must be submitted 24 Hours in advance of the appointment for a quote and to be scheduled*
Please fill out the form completely. Please note that an extra attendant (two-man) is required if the customer weighs more than 180lbs or if there are more than two stairs involved. Clearly mark an “X” in all boxes needing a response. Circle “Standing Order” if applicable.

TRIP INFORMATION



Requested Pick-up Date:
 
Requested Pick-up Time:
:


TRANSPORTATION DETAILS
Wheelchair-Standard Wheelchair-Wide
Stretcher Leg Extension Needed
Ambulette Extra Attendant Needed
Stairs (more than two)
Has Own Wheelchair?
                            Type->
DOCTOR/PCP INFORMATION

Name:
Phone #
Appointment Time: :
* Allow a minimum of 45 minutes between pick-up time and appointment time.

PATIENT INFORMATION
Name:
DOB:
Phone #
Weight (lbs)
First time using Monroe?
Yes  
No
Your Name: Confirm with: Confirmation Phone:

Notes/Special Needs/Et cetera:


Pick-up Address Destination Address
Facility:
Address:
City:
Zip Code:
Room #
Phone #
Contact Person
Facility:
Address:
City:
Zip Code:
Room #
Phone #
Contact Person


Would you like an email confirmation of the request?
Email Address


IMPORTANT:
Customer must be ready 45 minutes prior to appointment. The appointment office must be able to transfer the customer upon arrival or stand-by charges may apply.