Request Transportation | Legacy 1115 Transportation

Non-emergency transportation only. Legacy 1115 Transportation is not an ambulance or emergency medical service. If you are experiencing a medical emergency, call 911.

Requestor Information

Tell us who is submitting this transportation request.

Full Name *

Relationship to Passenger

Phone Number *

Email Address *

Preferred Contact Method *

Passenger Information

Provide information about the passenger who needs transportation.

Passenger Full Name *

Date of Birth

Passenger Phone

Transportation Type *

Wheelchair Type

Assistance Needed

Trip Details

Enter the pickup, destination and appointment information.

Pickup Address *

Destination / Facility Name *

Destination Address *

Appointment Date *

Appointment Time *

Requested Pickup Time

Trip Type *

Return Pickup Time

Recurring Transportation?

Recurring Schedule Details

Access & Special Instructions

Help us understand any access or assistance needs before the trip.

Escort / Support Person Traveling?

Stairs / Access Notes

Special Instructions

I understand that submitting this form is a transportation request only and does not guarantee availability or confirm a trip until Legacy 1115 Transportation contacts me.

Questions? Email info@legacy1115transport.com. Please do not use this form for emergencies.