Thank you for your trusting ZipCare as your source of transportation. To schedule a Self-Pay and Private Pay Trip, please fill out the form below. You will be prompted to submit payment. If you prefer to provide payment over the phone, please call us at (314)- 292-7302

ZipCare Self-Pay Request Form

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

First NameLast Name
Today's Date*

MonthDayYear
Date
Appointment Date*

MonthDayYear
Date
Appointment Time *
Please be sure to include the time of day (AM or PM)
Requested Pickup Time*
Please include a time you would liked to be picked up prior to your appointment
Do you need a return trip?*
Requested Pickup Time*
Time you would like to be picked up following your appointment
Number of Riders
Wheelchair Transport?*
Your Phone Number *
Please enter a valid phone number.
Your Email *
to receive confirmation the ride has been scheduled
Any additional details?
(floor, building number, etc)
Your Organization *
Please Add Your Trip Details *
Distance Cost (First 5 miles included, $3 per mile afterwards) *
Trip Cost (One-Way)*
Total Trip Cost *
How did you hear about us?

Payment Amount*

USDDescription

Credit Card

Apple Pay

Google Pay

Cash App Pay

ZipCare Self-Pay Request Form