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Transportation Request Form
Reliable transportation services for all of Southeast Michigan.

Option 1 - Download our form and then email or fax us your request. Click here to download the form as a PDF or Click here to download the form as a MS Word file
 
 
Option 2 - Fill out our online form below.
 
 
 Form 
Requestor Information
1.  Facility/Company Name*
2.  Address*
3.  City*
4.  State*
5.  ZipCode*
6.  Contact First Name*
7.  Contact Last Name*
8.  Contact Email*
9.  Contact Phone*
Trip Information
10.  Date of Service*
11.  Pickup Time
12.  Pickup Location*
13.  Pickup Address*
14.  Pickup City*
15.  Pickup State*
16.  Pickup Zipcode*
17.  Phone*
18.  Destination Name*
19.  Destination Address*
20.  Destination City*
21.  Destination State*
22.  Destination Zipcode*
23.  Dr./Contact Name*
24.  Contact Phone*
25.  Appointment Time*
26.  Return Time
27.  If unknown return time, would you like the driver to wait?
Yes
No
Will Call
28.  Special Instructions
(255 char max)
Patient/Client Information
29.  Patient First Name*
30.  Patient Last Name*
31.  Patient Phone*
32.  Patient Address*
33.  Patient City*
34.  Patient State*
35.  Patient Zipcode*
36.  Gender*
Male
Female
37.  DOB
38.  Ambulatory*
Yes
No
39.  If non-ambulatory, Approx. Weight
40.  Wheelchair: Motorized?*
Yes
No
41.  Wheelchair: Wide Chair?*
Yes
No
42.  Scooter w/ Steering?*
Yes
No
43.  Is additional person to assist needed?*
Yes
No
44.  Medical Restrictions/Special Accommodations Required
(255 char max)
45.  Claim #
46.  Nurse/Case Mgr
47.  Nurse/Case Mgr Phone
* required field     
 

 
Alimar Transportation
Services, Inc.
19701 Vernier Road, Suite 220
Harper Woods, MI 48225



Toll Free:
(866) 720–LIFT
 
 
Fax:
(313) 221–9475
 
 
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