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Gomedics performs intake to assess client needs and accommodations;
fleet suitability, safety concerns, client triggers and risk management matters.

Fields marked with an * are required

Name *

First

Last

Phone Number

Pick-up Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Drop-off Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Immediate/Emergency Contact

Name *

First

Last

Phone Number

Service Options

Pick-up only
Round-Trip
Wait-and-Return

Special Precautions

Do you require special accommodation under the AODA?
Do you require oxygen during transport?
Do you have any allergies or communicable diseases?
Do you have a condition that is contagious?
Do you frequently fall, have fractures or diagnosed with osteoporosis?
Will you be travelling with a service animal or travel companion?
Do you have any mental deficits, cognitive impairments, or history of mental illness?
Are you prone to violence or violent outburst due to a medical condition or otherwise?
Do you have any phobias, triggers, disorder, diagnoses or condition(s) that may adversely affect you in transit?

CONSENT

I consent to my Gomedics Drive Care Attendant being present when I see my physician/health care Provider.
I consent to Gomedics disclosing information about my visit to my caregiver, healthcare decision maker or designate.

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Feel free to ask us:

GO WITH CARE. GO WITH GOMEDICS!

Book Online Today!

1-416-941-2424
Toll-free: 1-(888) 992-7006
info@gomedics.ca

BOOK NOW

GO WITH CARE. GO WITH GOMEDICS!

Book Online Today!

1-416-941-2424
Toll-free: 1-(888) 942-7006
info@gomedics.ca

BOOK NOW

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