Online Booking Request & Rates Calculator

Booking Request

Please note that rates calculated on this reservation form will be based on the information provided by you. Enter pickup and drop off locations to get the estimate. We'll confirm vehicle availability by calling you back.

LAST MINUTE/SAME-DAY RESERVATIONS: For urgent bookings, please call 571-450-1300.

STAIR-LIFTER SERVICE: If you need to be transferred up or down stairs, we have especially built electric stair-lifter. The quoted price will increase each way due to additional stair-lifter service and additional personnel required for the trip.

WEIGHT: For patients over 250 lbs, additional charges for bariatric service will apply.

​CANCELLATION POLICY: We understand that sometimes appointments need to be cancelled and/or rescheduled. Please cancel/change an appointment at least 24 hours prior to the pick-up time to avoid fees. Changes/cancellations can be done by emailing us at bookings@vatransportationhealthcare.com or by calling 571-450-1300. For more information visit https://vatransportationhealthcare.com/refund-policy

SPECIAL INSTRUCTIONS: If you need to add any special comments, please add at the in Comments/Instructions section.

Patient’s First Name*

Patient’s Last Name*

Number of Passangers in Total *

Which facilities do you need during tansportation? * Wheelchair One-way Stretcher Roundtrip Stretcher One-way Covid Stretcher Roundtrip Covid Stretcher One-way Wheelchair Roundtrip Covid19 Wheelchair Oneway Covid19 Wheelchair Roundtrip Ambulatory One-way Ambulatory Round-trip Wheelchair One-way (with Stair Lifter) Wheelchair Roundtrip (with Stair Lifter)

Email*

Phone*

Booking Date *

Pickup Time *

Pickup Address *

Drop Off Address *

Patient Date of Birth*

Patient’s Weight (300lbs+ requires bariatric transport team)*

Who is paying for the trip? Private Pay Facility Other

Are there any stairs involved to move the patient downstairs/upstairs? If yes, how many? *

Do you need electric stair-lifter service (moves patient comfortably over the stairs)? * No Yes

Is there any wait time involved? * No Yes

How much time needed? * 60 Minutes 120 Minutes

Comments or Instructions

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