Transportation

Transportion Request Form

Empire State Medi-Cab
P.O Box 8448
Jupiter, FL 33468
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Phone: 631-777-7333
Fax: 631-777-7335
Email:

When possible, please try and schedule your transports at least 2 days in advance for scheduled medical appointments. We understand certain transports are needed with short or same day notice and we are here to help you. We welcome those spur of the moment transports and will work with you to make the best of a seemingly impossible transportation situation.

Note: For short term and same day transports, refrain from using our email option to schedule your transport. Calling our team will result in the best scheduling outcome.

To set up a trip with Empire State Medi-Cab, please fill out the form below. We will contact you with confirmation for your requested trip. If you do not here from us within one day, please contact our service team.

Fields marked with an * are required.

Transportation Request Form:

Transport Information

Date of Transport:*

Time of Appointment:*

Name of Customer:*

Pickup Address:*

Destination Address:*

Special Requests:

Approximate Length of Appointment:*

Payment Method (Private/Insurance):*
If Medicaid, please provide the Medicaid number of the customer

Contact Information:*

How Did You Hear About Us:

7 tips for setting up your transport. Know the following:

Name of customer
Date and time of appointment
Pickup and destination addresses
Special Requests
Approximate length of appointment
Payment method
Emergency contact information

Direction

"If you don't know where you are going, you'll end up someplace else." — Yogi Berra

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Empire State Medi-Cab - A Premier Ambulette Service

Transportation

Transportion Request Form

Transport Information

7 tips for setting up your transport. Know the following:

Direction