Medical Pilot Booking Form

Booking enquiry form for Bendigo / Heathcote medical specialist access corridor pilot.

Referring Doctor's Details

Referring Doctors Name(Required)

Untitled(Required)

Referring Doctor's Phone(Required)

Patient Details

Patient's First & Last Name(Required)

Patient's Email(Required)

Patient's Phone(Required)

Patient's HOME ADDRESS (pickup location)*(Required)

Street Address Address Line 2 City ZIP / Postal Code

Destination Details

Destination(Required)

Address for Specialist (dropoff location)*(Required)

Street Address Address Line 2 City ZIP / Postal Code

Appointment Date and Time (if known)

Appointment Date (if known)

Appointment Time (if known)

Special Needs

Message

Choose as applicable

Wheelchair

Wheely Walker

Requires Carer at Destination

Requires Carer throughout Journey

Help with general welfare, social and mobility issues

Help getting to the appointment location

Help with language, cultural or vulnerability needs

Companion(s) may join patient on the trip

All travel and/or special needs requirements are subject to confirmation by LINK Community & Transport.u000b(additional costs may apply)

To Complete

Please click the "captcha validation" and click submit. We will contact you shortly. Your transport booking, or any special assistance requirements are not final until you have had confirmation from us of our acceptance of your request and our agreement to provide transport. Please use an alternative service if your needs are urgent, emergency, or require medicalised support.

Captcha Validation

Comments

This field is for validation purposes and should be left unchanged.