Book a Ride — UltraCare Transport

Trip Type Step 1 of 6

What type of ride do you need?

Select one to get started

🏥

Medical Appointment

Doctor, specialist, clinic, surgery

💧

Dialysis Transport

Recurring dialysis schedule

🏠

Hospital Discharge

Going home after hospital stay

Patient Information

Who is being transported?

Full Name *

Please enter the patient's full name

Phone Number *

Please enter a valid phone number

Email Address

Preferred Contact Method *

Please select a contact method

Who is filling out this form? *

Please select who is filling this out

Pickup Location

Where should we pick up the patient?

Street Address *

Please enter the pickup street address

City *

Required

State

ZIP Code *

Required

Destination

Where is the patient going?

Facility / Hospital Name *

Please enter the destination name

Street Address

City *

Required

State

ZIP Code *

Required

Appointment Details

When is the appointment?

Appointment Date *

Please select a date

Appointment Time *

Please select a time

Round Trip or One Way? *

Round Trip I need pickup and return ride

One Way Pickup only, no return needed

Please select round trip or one way

Mobility Needs

Help us send the right vehicle

Mobility Type *

Ambulatory Walks independently

Manual Wheelchair Wheelchair-accessible vehicle required

Power Wheelchair Wheelchair-accessible vehicle required

Other Mobility Device Walker, cane, etc.

Please select mobility type

Assistance needed? *

Required

Caregiver accompanying?

How will this be paid?

Select your payment method

💳

Private Pay

Credit or debit card

🛡️

Private Insurance

Commercial health plan

🏛️

Medicare

Federal Medicare coverage

🏥

Medicaid

Texas Medicaid / STAR

Please select a payment method

Insurance Information

Insurance Company *

Required

Member ID *

Required

Group Number

Patient Date of Birth *

Required

Got it. A team member will contact you to verify your coverage and confirm eligibility before your trip. No action needed on your end right now.

Review Your Request

Please confirm your details before submitting

Special Notes

Anything the driver should know? (optional)

How did you hear about us?

By submitting this form, I consent to UltraCare Transport contacting me by phone, text, or email to confirm my ride and provide transportation services. I understand my information is kept confidential and used only for scheduling purposes. View our Privacy Policy.

Request Received!

⏱ We'll contact you within 2 hours

Thank you for choosing UltraCare Transport. A coordinator will reach out to confirm your ride details and send your payment link.

Questions? Call or text us at (909) 918-4775

Book Your Medical Transport

Request Received!