Vantage Transports Incorporated

Name of Service	:
Name of Patient	: This is a required field. This is a required field. First Name Surname

Street Address	:
City	:
State	:
Telephone Numbers	:
Email Address	:
Date of Birth	: Please enter a valid date.
Gender	: Male Female
Social Security No.	: - - (Format: 123-45-6789) Please enter a valid social security number.
Medical ID No.	: - - (Format: 8 digits + 1 letter + 5 digits ) Please enter a valid medical ID number.
Medical ID No. Date of Issue	: Please enter a valid date.

PRIVATE PAY BILLING INFO:
Responsible Party	:
Street Address	:
City	:
State	:
Telephone No.	:
Days of Service	:
Chair/Appointment Time	: : : Please enter a valid chair time.
Duration	: hour(s) minute(s) Please enter a valid duration.
Preferred Pick-up Time	: : : Please enter a valid pick-up time.
Preferred Return Time	: : : (must be above the pick-up time) Please enter a valid return time.

Clinic Facility Name	:
Clinic Facility Address	:
Name of Doctor	:

ASSISTIVE DEVICE
Wheelchair	: Yes No Others:
If wheelchair, can transfer:	: Yes No

PLEASE ANSWER:
1. What limiting condition prevents you from taking private or public transportation?
This is a required field.
This is a required field. This is a required field. I have stopped riding with since and have since been riding with Vantage Transports. I voluntarily enroll myself to be transported by Vantage Transports and do this freely without any pressure from the Clinic or Vantage Transports. I also understand that I may stop riding with Vantage Transports at anytime I choose to do so. I authorize release of medical information to Vantage Transports so they may have the necessary information to get transportation approved by Medi-Cal.