Thank you for your interest in ZipCare! We would be honored to serve you. Please request transportation by completing the information below. We will send you a trip confirmation upon receipt.

ZipCare Transportation Request Form

For any urgent questions please email: dispatch@zipcare.com
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Appointment Date*

MonthDayYear
Date
Appointment Time *
ex (9:00 AM CST)
Number of Riders*
Wheelchair Transport?*
Your Phone Number *
Please enter a valid phone number.
Your Email *
to receive confirmation the ride has been scheduled
Pickup Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Drop Off Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Any additional details?
(floor, building number, etc)
Do you need a return trip?*
Return Pickup Time
ex (9:00 AM CST)
Client Phone Number*
Please enter a valid phone number.
Your Organization *
How did you hear about us?
Should be Empty:

ZipCare Transportation Request Form