Request a Ride with Rollin VIP Transportation

Complete the form below to request non-emergency transportation. Submitting this form does not guarantee availability. A team member will confirm your ride.

⚠️ Please Note:

Advance notice is required
This is non-emergency transportation
Same-day rides subject to availability
A confirmation call/text will follow

Request A Ride Form

Rider Information

Full Name *

Date of birth

Phone *

Email

Pickup Information

Pickup Address *

Pickup Date *

Pickup Time *

Drop-off Information

Drop-Off Address *

Type of Destination *

Other Destination Type

Appointment Time (if applicable)

Mobility & Accessibility Needs

Other Needs

Trip Type

One-Way or Round-Trip *

Recurring Ride? *

Yes

No

Additional Details

Medical Notes / Special Instructions

Emergency Contact

How do you plan to pay for this ride?

Payment details are not collected on this form. After submitting your request, our team will contact you to confirm eligibility, pricing, and next steps.

Other Payment Option

Terms & Conditions Agreement

By submitting this form, I acknowledge and agree that:

I am requesting non-emergency medical or community transportation services from Rollin VIP Transportation.
Rollin VIP Transportation does not provide emergency services. In the event of an emergency, I understand that I should call 911 or my local emergency services.
Ride requests are subject to availability, scheduling confirmation, and service area limits.
I understand that providing accurate pickup, drop-off, and contact information is my responsibility and may affect service delivery.
I understand that cancellations or no-shows may require advance notice and may be subject to service policies explained upon confirmation.
Submission of this form does not guarantee service until my ride has been confirmed by Rollin VIP Transportation.

SMS Communication Consent

By checking this box, I consent to receive SMS/text messages from Rollin VIP Transportation regarding my ride request, including scheduling confirmations, reminders, updates, and service-related notifications.

Message frequency may vary.
Message and data rates may apply.
Consent is not a condition of purchase or service.
I may opt out at any time by replying STOP.
For help, I may reply HELP or contact Rollin VIP Transportation directly.

We respect your privacy. Your information will only be used to provide transportation services and communicate about your request. We do not sell or share personal information.

Privacy Policy | Terms of Service

What Happens After You Submit

✅ Our team reviews your request (usually within 1 business day)
📞 We’ll contact you to confirm ride details and availability
💳 Payment and eligibility are finalized after confirmation
🚐 Once approved, your ride is officially scheduled

Important Notes / Expectations

Submitting this form does not guarantee a ride until confirmed by Rollin VIP Transportation
Same-day requests are subject to availability
Cancellations require advance notice to avoid fees

Need help or have questions about your request?
📞 Call or text us at (555) 555-5555

Serving medical, senior, and community riders

Rollin VIP Transportation
Reliable Non-Emergency Medical & Community Transportation

- Minority woman-owned

- Community-focused

- Professional & dependable

COMPANY

Non-Emergency Medical Transportation (NEMT)
Dialysis Transportation
Therapy & Rehabilitation Rides
Senior Transportation
Community & Essential Errands

CONTACT & SUPPORT

📞 Phone: [Business Phone Number]
💬 Text: [Text-enabled Number]
✉️ Email: [email protected]
🕒 Hours: Mon–Fri 9AM-7PM CST

LEGAL

Rollin VIP Transportation provides non-emergency transportation services only.
For medical emergencies, call 911.