Patient Book A Ride Form

Patient Booking

Select Where You Live*

Patients First and Last Name*

Is Contact Person different from Patient?*

YES

Contact Person*

Cell Number*

Home Phone*

Email*

Postal Code*

Are you a New Patient or Returning Patient?*

If you have NOT USED our services before, select “NEW PATIENT” to register.

Returning Patient

New Patient

New Patient Registration

Patient Pick Up Address*

City*

Accommodations*

Mobility Aid / Car Seat

COVID-19 Vaccination Status*

Fully Vaccinated is defined as 2 or more shots.

Emergency Contacts Name*

Relationship*

Emergency Contact Number*

How did you hear about us?*

Age Group*

Would you like to request rides for upcoming cancer treatment appointments?*

Not Today

Yes

You may book up to 5 rides

General Comments

You may book up to 5 rides

Appointment 1 – Date*

Appointment 1 – Time*

Appointment 1 – Length*

Treatment Centre*

Indicate Other Destination*

Reason*

Indicate Other Reason*

Trip Type*

Round Trip

One Way to Treatment

One way from Treatment

# of Passengers*

Booking a 2nd appointment?*

Not Today

Yes

Appointment 2 – Date*

Appointment 2 – Time*

Appointment 2 – Length*

Treatment Centre*

Indicate Other Destination*

Reason*

Indicate Other Reason*

Trip Type*

Round Trip

One Way

# of Passengers*

Book a 3rd appointment?*

Not Today

Yes

Appointment 3 – Date*

Appointment 3 – Time*

Appointment 3 – Length*

Treatment Centre*

Indicate Other Destination*

Reason*

Indicate Other Reason*

Trip Type*

Round Trip

One Way

# of Passengers*

Booking a 4th appointment?*

Not Today

Yes

Appointment 4 – Date*

Appointment 4 – Time*

Appointment 4 – Length*

Treatment Centre*

Indicate Other Destination*

Reason*

Indicate Other Reason*

Trip Type*

Round Trip

One Way

# of Passengers*

Booking a 5th appointment?*

Not Today

Yes

Appointment 5 – Date*

Appointment 5 – Time*

Appointment 5 – Length*

Treatment Centre*

Indicate Other Destination*

Reason*

Indicate Other Reason*

Trip Type*

Round Trip

One Way

# of Passengers*

SUBMIT to complete the form.
After “Submitting” your form a confirmation message will be sent to your email address. If you do not see the confirmation, please look in your spam or junk folder.

The Volunteer Cancer Drivers Society is an all-volunteer organization. We require that patients and their families treat our volunteers with respect. There will be zero tolerance for disrespectful or aggressive behaviour toward our volunteers.

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