Please complete all fields below. If you qualify, a coordinator will contact you within 24-48 business hours to confirm your scheduled pick-up time for next week.

Full Name *

Date of birth *

Phone *

Address

Home Address (Please note: Service is limited to patients within a 3-mile radius of our facility.) *

City *

State *

Country

Postal Code *

Appointment/Shuttle Pick-Up Time Request *

By checking this box, I consent to receive non-marketing text messages from EPIC Health about transportation services. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from EPIC Health at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.