Schedule Transportation for Your Patient or Resident

For established Chisholm Trail Transportation facility accounts. Complete the request below and a CTT representative will confirm receipt and scheduling.

Important: Submitting this form sends a transportation request. Transportation is not confirmed until a CTT representative contacts you by phone or email.

1

Facility / Requestor

Established CTT Account Name(Required)

Requestor Name(Required)

Direct Phone Number(Required)

Email Address(Required)

Preferred Confirmation *(Required)

2

Passenger Information

First Initial(Required)

Last Name(Required)

Date of Birth(Required)

Room Number

Approx. Weight(Required)

Mobility(Required)

Passenger riding with or meeting someone?(Required)

Yes

No

3

Appointment Details

Appointment Date(Required)

Appointment Time(Required)

HH

:

MM

Pickup timing: Pickup is normally scheduled 30 minutes before the appointment. If the appointment destination is outside city limits, CTT will determine the appropriate pickup time and confirm it with you.

Appointment Address(Required)

Suite Number

Doctor or Clinic Name

4

Return Transportation

Appointments are considered round trip unless otherwise specified.

CTT drivers leave a card with the receptionist, facility staff, or passenger to call when the passenger is ready for return transportation.

Return to Facility after appointment

Return to Patient's Residence - Discharge

Other / One Way

Patient Residence / Discharge Address(Required)

Next of Kin / Family Contact Name(Required)

Next of Kin / Family Contact Phone

5

Transportation Notes

Additional Instructions

Please do not include diagnosis, medical record number, Social Security number, insurance information, or other unnecessary medical information.

Confirmation required: A CTT representative will call or email you, based on your preference above, to confirm that your request has been received and scheduled. Your trip is not confirmed until you receive that confirmation.

A CTT representative should confirm your appointment within 15 minutes. Thank you for your patience.

Need immediate assistance? Call CTT at 817-897-RIDE (7433).

Schedule Transportation for Your Patient or Resident

Facility / Requestor

Passenger Information

Appointment Details

Return Transportation

Transportation Notes

Chisholm Trail Transportation LLC