Nurtec Transportation LLC
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Questionnaire for Potential Clients
Thank you for choosing Nurtec Transportation LLC! We are a non-emergency medical transportation company that provides reliable services in the Brandon, Riverview, and surrounding Hillsborough county area. We offer door-to-door transportation to locations such as adult day centers, doctor appointments, and legal appointments.
Please complete the form below. Once you submit, we will call you within 3 business days to answer any questions you may have about pricing, route scheduling, and insurance coverage (if applicable). We do accept Medicaid but restrictions apply based on coverage.
Check Box If This Applies To You:
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I am completing this questionnaire for someone who is unable to complete it for themselves.
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Indicates required field
Name of Person to be Serviced:
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First
Last
Complete Address of Person to be Serviced:
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number of Person to be Serviced::
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Name of Guardian or Person Responsible for Client
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First
Last
If someone else is legally responsible for client, enter their information here. Ideally, this person should be completing this questionnaire.
Address of Guardian or Person Responsible for Client:
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Line 1
Line 2
City
State
Zip Code
Country
Guardian/Legal Rep. Phone Number
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Is Client able to walk without assistance getting into and out of a vehicle?
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YES
NO
If NO, what type of medical device is used? (Check All that Apply)
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Wheelchair
Walker
Cane
Other (specify in comments)
Does Wheelchair require lift or ramp?
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Does Not Apply
YES
NO
If NO, will Client need space for a fold-up wheelchair?
*
Does Not Apply
YES
NO
What times would you MOST want to use the transportation service? (Check All That Apply)
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6 am to 9 am
9 am to 12 noon
12 noon to 5 pm
What days of the week would you be most likely to travel locally using a transportation service? (Check All That Apply)
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Monday
Tuesday
Wednesday
Thursday
Friday
In an average week, how many vehicle trips (include a round trip as TWO trips)? (Choose ONE that most applies)
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None
1 - 5
6 - 10
11 - 15
16 - 20
More than 20
FOR PRIVATE PAY CLIENTS & CLIENTS BEING TRANSPORTED TO APPOINTMENTS ONLY:
Will Client require Escort to Accompany You?
*
Does Not Apply
YES
NO
FOR MEDICAID CLIENTS ONLY:
Name of Support Coordinator:
*
Support Coordinator Phone Number:
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Support Coordinator Fax Number:
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Support Coordinator Email Address:
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ADDITIONAL COMMENTS ABOUT CLIENT:
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Submit
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