Facility Booking - Bridgepoint Mobility

Facility Booking Form

Bridgepoint Mobility makes it easy for our facility partners to schedule reliable, non-emergency medical transportation for residents and patients. Please complete the form below to request transportation.
Transportation requests should be submitted at least 24 hours in advance.
All requests are subject to availability and will be confirmed by Bridgepoint Mobility.

Pick Up

Facility Name *

Coordinator *

Email *

Member Name *

First

Last

Additional Information

From Location Name *

Requested Pickup Date Time *

Date

Time

Phone

Type Of Assistance Needed

Curb To Curb
Walking Assistance
Door To Door

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Building

Apartment

Name Of Doctor

Drop Off

To Location Name *

Appointment Time *

Date

Time

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Building

Trip Duration

If Choosing Round Trip

Trip Duration *

One Way
Round Trip

Will You Need The Driver To Wait During Your Appointment? *

No – I Will Contact Bridgepoint When I'm Ready For Return Pickup
Yes – Wait And Return Requested (Additional Wait Time Fees May Apply)

Directions For Driver

Name