Medical Travel Assistance Program - Van Intake Form

Are you applying on behalf of a child/minor

Yes

No

Will you require a return trip?

Yes

No

Do you require transportation after the appointment?

Yes

No

Will you require the use of a lift to board the van?

Yes

No

Will you be requiring recurring travel bookings to accommodate set recurring appointments? (I.e. Dialysis)

Yes

No

Are the appointment times and day of the week same as above?

Yes

No

Medical Van Intake Form