Book a Ride | MyPanion

SMS Notifications (Required)

I agree to receive appointment text notifications including:

Booking confirmation
Caregiver assignment and arrival updates
Appointment reminders
Pickup, in-transit, and drop-off notifications

Text messages will be sent to the phone number(s) provided above. Reply STOP to opt out at any time. Standard message/data rates may apply.

Emergency Contact (Required)

Person to contact if we cannot reach you during transport

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Patient Mobility & Safety Information (Required)

This helps us provide safe and appropriate assistance

Mobility Level *

Fully mobile (walks independently)

Needs assistance walking

Uses walker or cane

Uses wheelchair

Non-ambulatory (requires stretcher/gurney)

Medical Considerations (Check all that apply)

Requires oxygen

Has mobility device (walker, cane, wheelchair)

Has difficulty with stairs

Needs assistance getting in/out of vehicle

Additional Medical Considerations or Special Needs

Helpful Suggestions Based on Your Needs

Based on what you've shared, these services might be helpful:

Additional Service Needs

A few quick questions to help us personalize your service and save you time

Will you need to fill a prescription after your appointment?

Need to pick up groceries or essentials on the way home?

Have another quick errand to run?

Examples: Post office, bank, pick up forms

Note: Add-ons include their own time windows. If the overall visit runs long, one flat overtime adjustment may apply—never per add-on billing.

Appointment Details

Doctor/Facility Name *

Appointment Type (Optional)

Appointment Date *

Appointment Time *

Estimated Appointment Duration *

Include time for check-in, waiting, appointment, and check-out

Pickup Address *

Pickup Instructions (Optional)

Clinic/Facility Address *

Facility Instructions (Optional)

Round Trip Service (Included)

All MyPanion plans include complete round-trip service:

Pickup from your home
Transport to appointment
Caregiver stays on-site during your entire appointment
Transport back home

Important: Select a plan with enough included time to cover your entire appointment duration to avoid additional fees.

Select Your Service Plan

Basic $95

Includes 2.0 hours of service

Perfect for routine appointments

Standard $125

Includes 2.5 hours of service

Great for longer appointments

Premium $165

Includes 3.5 hours of service

Best for complex visits with extra support options

Your Selected Add-Ons

🦽 Wheelchair Assist (+$10)

Caregiver provides and manages wheelchair throughout appointment

🤝 Transfer Assist (+$15)

Specialized support for vehicle entry/exit and stair navigation - 15 min included

💊 Pharmacy Stop (+$15)

Pickup on return route - 20 min total (15 + 5 grace)

🛒 Grocery Stop (+$30)

Essentials or curbside pickup - 40 min total (30 + 10 grace)

📍 Extra Stop (+$15)

Quick errand (post office, bank, etc.) - 15 min total (10 + 5 grace)

🚗 Long Distance 20-40 mi (+$40)

For appointments 20-40 miles from pickup location

🚗 Long Distance 40-75 mi (+$75)

For appointments 40-75 miles from pickup location

Your Booking Summary

Basic Plan $95

Estimated Total: $95

Payment Method: You'll receive a secure Stripe payment link via SMS after we confirm caregiver availability. No payment is collected on this form.

Payment Information

After booking confirmation:

We'll verify caregiver availability (typically 15-30 minutes)
You'll receive a secure Stripe payment link via SMS
Payment must be completed to confirm your booking
No payment is collected on this form

Note: If appointment delays cause significant wait time beyond your plan, a one-time Long-Wait Adjustment ($15 or $25) may apply. No hourly charges.

Additional Notes

Additional Information (Optional)

Required Agreements

Cancellation Policy Agreement

I understand and agree to the cancellation policy:

FREE cancellation: More than 24 hours before appointment
25% cancellation fee: Less than 24 hours before appointment
50% cancellation fee: No-show or same-day cancellation
Emergency exceptions may apply - contact us immediately if needed

View full cancellation policy

Service Agreement & Liability Waiver

I acknowledge and agree that:

MyPanion provides NON-EMERGENCY medical transportation only
For medical emergencies, I will call 911 immediately
I release MyPanion and its caregivers from liability for medical conditions or emergencies during transport
All information I provided is accurate to the best of my knowledge
I agree to MyPanion's Terms of Service and Privacy Policy

View Terms of Service View Privacy Policy

Book Your Medical Transportation

Important: Non-Emergency Service Only

SMS Notifications (Required)

Helpful Suggestions Based on Your Needs

Wheelchair Assist - $10

Transfer Assist - $15

Round Trip Service (Included)

Currently Selected:

Your Booking Summary

Premium Benefits & Options

Consent Required for Exam Room Escort

Your 3 Questions for the Doctor

Payment Information