Request a ride

Request Transportation

Complete the form below to tell us about your transportation needs. Submitting this form does not automatically confirm the ride. A Peavanta representative will contact you to review availability and trip details.

Leave this empty

Passenger

Who is travelling, and how we can reach you.

Passenger name Person making the request If different from the passenger

Telephone number Email address

Trip

Where and when. If you are not sure of a time, give your best estimate.

Pickup address

Destination name and address

Appointment date Appointment time Requested pickup time Optional

Trip type

One-way Round trip

Expected return time If known

Number of passengers

Recurring transportation needed?

Yes No

Assistance and details

Please do not include diagnoses, medical record numbers or other medical details. We only need what is required to plan the trip.

Mobility or assistance information For example: uses a cane or walker, needs help to the door, a caregiver will travel along.

Additional trip details Anything else that helps us plan the trip.

Preferred contact method

Phone call Text message Email

We respond during business hours: Mon to Fri, 6:00 a.m. to 7:00 p.m. · Sat by appointment.