Non-Emergency Medical Transport

Transportation Request

Complete this form and our team will reach out within 24 hours to confirm your ride.

1. Contact Information

Your Details

First Name*

Last Name*

Phone*

Email*

Patient Name (if different)

2. Pickup & Destination

Pickup Address

Street Address*

City*

ZIP Code*

Destination

Appointment Type*

Facility / Doctor Name

Destination Address*

City*

ZIP Code*

3. Schedule & Needs

Appointment Details

Preferred Date*

Appointment Time*

Round TripInclude return ride

WheelchairAccessible vehicle needed

4. Insurance

Coverage

Insurance Provider*

Member ID (optional)

5. Additional Information

Special Instructions

I consent to Best Friends Health Care Services LLC contacting me regarding my transportation inquiry. My information will be handled in accordance with HIPAA and Texas HB 300 privacy requirements.

We'll confirm your ride within 24 hours. For urgent transportation needs, call 713-485-6989.