USE this link to submit: https://app.okridecare.com/?page=transport-request-form&requesterId=SCLHSA

Do not use this form. Thanks for your help.

Client Name

Submission Date

mm/dd/yyyy

Is client under 18 year of age?

Client Information

Date of Birth

mm/dd/yyyy

Social Security Number

Height

Weight

Gender

Referring Information

Referring Entity

Referring Contact Name

Referring Contact Phone Number

Dispatchers will call this number to confirm details of the transport and give ETA. If no one answers, the trip will be delayed.

Phone

Referring Contact Email

Pick Up Address and Location

Is this trip an appointment or emergency?

Destination Information

Destination Facility

Destination Facility Address

Destination Facility Contact Name

Destination Contact Phone Number

Phone

Additional Information

Special Precautions or Medical Concerns

Examples: Suicide/Self Harm, Elopement Risk, ADA Needs, Seizures, Diabetic, Tirggering Elements, etc.

History of Violence:

Aggressive or Violent today?

Special Needs/Concerns

Is the client medically cleared for transport?

Will the client be ready when the driver arrives?

IMPORTANT!

If you experience any type of issue, please call our dispatch center at 800-690-4305. That is the most efficient way of resolving transport issues.