Medicare Comfort Transport
You can book your ride online by completing the form below.
Need help booking a ride? If completing the form feels difficult or time-consuming, call us at 602-497-7670 and our team will take care of everything for you.
Book For Please select type of booking.One-Way TripRound Trip
Type of Service Requesting - Please Select -WheelchairAmbulatoryMedical ProcedureDialysisOther
First Name
Last Name
Patient's Phone Number
Email Address
Relationship to Patient
Patient's Name
Patient's Age
Customer’s Age
Customer’s Estimated Weight
Would You Want The Driver To Wait At Drop-Off?
YesNo
Estimated Wait-Time
0-1 hour1-2 hour2-3 hour3+ hour
Pickup Address
Street Number and Name
Apartment or Suite Number
City
State Please select state.AlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip
Date
Pick up time
Appointment Time
Drop Off Address
Should we provide a wheelchair?
Do you need wheelchair assistance?
Where do you need assistance - Please select -At pick up onlyAt drop off onlyBothNone
Who are you traveling with caregiver/family - Please select -FamilyCaregiverNone
Do you need a Patient Escort Service i Our Patient Escort Service is a non-clinical service providing full assistance during doctor visits. We assist during grocery shopping, salon or barber visits, and more. Trained escorts help with wheelchair transfers. We remain with your loved ones during appointments and provide updates. Escort from home to transportation and ride along as a dedicated aid. Support anytime when travel becomes necessary. We wait with your loved one until you arrive. Our escorts are compassionate, reliable, and well trained. Our goal is long-term trusted relationships. Book our service and experience flexibility and care.
Receiving Facility Name
Receiving Facility Phone Number
Accompanying Person(s) (person must be 18 years old or older) - Please select number of person to accompany. -0123
Additional Information or Brief Description of Service Needed
