Book a Ride

Who is riding?

We’ll use this to confirm your ride.

Rider’s full name *

Phone *Best number to confirm the ride

Email *In case dispatch needs to email you

I am booking for

Myself

Family / friend

Facility / case manager

Your name (if different from rider)

Facility name & your name

Trip details

Where are we picking up and where are you going?

Pickup address *Street, city, ZIP — add apartment, building or room number

Drop-off address *Facility name and address (e.g., dialysis center, hospital)

Date *

Pickup time *

Appointment time

Trip type *

One-waySingle trip

Round tripWe bring you back

Return dateLeave blank if same day

Return pickup time *Best estimate is fine — we adjust in real time

I’ll call when ready for the return pickup

Estimated fareFare will be quoted by dispatch

Mobility & special needs

This helps us send the right vehicle and crew.

Mode of transport *

AmbulatoryWalks, may need assistance

WheelchairWheelchair van with lift

StretcherBLS ambulance, 2 EMTs

Wheelchair

Optional add-onsAdded once per booking (not per leg)

Do you need us to wait during the appointment? (+$35/hour; BLS stretcher +$80/hour)

Yes, please waitBilled per hour of waiting

NoNo waiting needed

How long is the appointment? *We charge for each hour the driver waits. For 5+ hours the estimate uses 5 hours; dispatch confirms the final wait time.

Patient needs oxygen (+$40)

Steps at pickup

Steps at drop-off

Approx. weight (lbs)

A companion / caregiver will ride along

Special needs or notesOxygen, walker, door code, language, etc. Please don’t include diagnoses or ID numbers.

Payment

How will this ride be paid for?

Payment method *

InsuranceMedicare, ModivCare, Horizon…

Private paySelf / family / facility

Insurance plan * Do not enter member ID numbers here — we’ll collect them securely by phone.

Review your request

Check everything looks right, then send.

I understand this is a ride request: Medex will call to confirm availability and details. This service is not for emergencies — in an emergency I will call 911.

Ride request sent

Almost done — send your request

Reference number:

Thank you! Your request was sent to our dispatch team. Dispatch will call you shortly to confirm your ride — your ride is not confirmed until you hear from us.

Your email app should open with your ride request filled in — please press Send to deliver it. If it didn’t open, click here. Your ride is not confirmed until our team calls you.

Need it sooner or have a change? Call 732-490-5300.

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