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WALEED TEST FORM

Input

ONE WAY OR ROUND TRIP ?

One Way

Round Trip

Pickup Address

Pickup Date

Pickup Time

Drop off Address

Please Confirm Drop Off Address

Appointment Time

Estimate Return Pickup

First Name

Last Name

Is This Ride For You or Someone Else?

For Me

For Someone Else

What's the Passengers Full Name?

Phone Number

I understand that MedCare Transport exclusively accepts private pay and does not participate in any insurance programs

I Agree

Output

Distance From Main Office to Pickup Location

Miles

Distance From Pickup To Drop Off Location

Miles

Loaded Distance

Miles

Unloaded Distance

Miles

Loaded Distance

Miles

Unloaded Distance

Miles

One Way Ambulatory Rates:

One Way Wheelchair Rates:

One Way 3-Gurney Rates:

Two Ambulatory Rates:

two way 2- Wheelchair Rates:

two way 3-Gurney Rates:

Total Cost:

Calculations ( Not visible )

Main Office 1

Main Office 2

Drop off to main office 1

Drop off to office 2

Short Distance between main office to pickup

Short Distance between main office and drop off:

From Pickup to Drop off

One Way

Calculation Field

Pickup Location

lat

lan

Text

If you are human, leave this field blank.