Book a Companion | MyPanion

SMS Notifications (Required)

I agree to receive appointment text notifications including:

Booking confirmation
Companion 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 the appointment

Emergency Contact Name *

Emergency Contact Phone *

Relationship *

Client 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

Assistance Needs (Check all that apply)

Has mobility device (walker, cane, wheelchair)

Has difficulty with stairs

Needs assistance getting in/out of vehicle

Additional Considerations or Special Needs

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 extended care 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)

Complete Accompaniment Service (Included)

All MyPanion plans include complete door-through-door companion service:

Pickup from your home
Accompaniment to your appointment
Companion stays with you during your entire appointment
Accompaniment back home

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

Make This a Recurring Booking?

Yes, I need this appointment on a regular schedule

Perfect for dialysis, physical therapy, or regular doctor visits. We'll automatically book your appointments and try to assign the same caregiver.

Recurring Schedule Settings

Frequency *

Day of Week *

End After *

How it works: After your first booking, we'll automatically create future bookings 7 days in advance. You'll receive SMS confirmations for each booking and can cancel or modify individual bookings anytime.

Select Your Care Plan

Basic $95

Includes 2.0 hours of care

Perfect for routine appointments

Standard $125

Includes 2.5 hours of care

Great for longer appointments

Premium $165

Includes 3.5 hours of care

Best for complex visits with extra support options

Your Selected Add-Ons

♿ Wheelchair Assistance (+$10)

Companion helps client transfer from wheelchair to vehicle and stores wheelchair

🤝 Transfer Assistance (+$15)

Hands-on support for sitting, standing, and mobility

💊 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)

🚗 Extended Distance 20-40 mi (+$40)

For appointments 20-40 miles from pickup location

🚗 Extended Distance 40-75 mi (+$75)

For appointments 40-75 miles from pickup location

Your Booking Summary

Basic Plan $95

Have a discount code?

Estimated Total: $95

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

Payment Information

After booking confirmation:

We'll verify companion 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 Extended Care 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: 12-24 hours before appointment
50% cancellation fee: Less than 12 hours before OR no-show
Emergency exceptions may apply - contact us immediately if needed

View full cancellation policy

Service Agreement & Liability Waiver

I acknowledge and agree that:

MyPanion provides companion care services for non-emergency appointments only
For medical emergencies, I will call 911 immediately
I release MyPanion and its companions from liability for medical conditions or emergencies during service
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 Companion

Important: Non-Emergency Service Only

We Found Your Information

SMS Notifications (Required)

Helpful Suggestions Based on Your Needs

Wheelchair Assistance - $10

Transfer Assistance - $15

Complete Accompaniment Service (Included)

Recurring Schedule Settings

Currently Selected:

Your Booking Summary

Premium Benefits & Options

Consent Required for Exam Room Escort

Your 3 Questions for the Doctor

Payment Information

Review Your Booking