Travel Request Client Information Client Name Client Name First Name First Name Last Name Last Name Birthday Address Address Address Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Zip Medical Conditions / Illnesses / Complications: Medications: Allergies: Primary Contact/Responsible Party Name Relationship to Client Phone Email Emergency Contact Name Phone Services Information Services Requested Transportation to Doctor Appointments Social Outings/Errands Airport Transportation Flying Companion Services OtherOther Does your loved one have any special needs? Yes No Please explain Does your loved one have any physical disabilities or mobility limitations? Yes No Please explain Does your loved one use any assistive devices? (check all that apply) Wheelchair Walker Cane Brace OtherOther Does your loved one have any hearing loss? Yes No Use Hearing Aids Does your loved one have any vision impairments? Yes No Does your loved one have memory needs, memory impairment, or cognitive challenges? Yes No Please Describe Has your loved one had any history of falling within the past 12 months? Yes No How many falls, were there an injuries? Does your loved one require assistance getting in or out of a vehicle? Yes No Does your loved one experience dizziness, balance issues, or fatigue? Yes No Does your loved one have any anxiety related to transportation or appointments? Yes No Are there any behavioral considerations we should be aware of? Yes No Please explain Does your loved one have any medical equipment we should be aware of? Oxygen Portable medical devices None OtherOther Emergency Medical Preferences DNR Yes DNR No Unsure Preferred Hospital if outside service area Are there any allergies or sensitivities we should know about? Yes No Please explain Preferred method of communication: Verbal Written Caregiver only OtherOther Is there anything else we should know to better care for and assist your loved one? ACKNOWLEDGMENT I confirm that the information provided above is accurate and complete to the best of my knowledge. Yes Client / Authorized Representative Name: Signature signature keyboard Clear Submit If you are human, leave this field blank.
