TRIP RESERVATION FORM – Insurance, Medical, Legal

* Indicates Response Required

Requesting Company

Company Name

Lawyer on File Name

Have you booked with us before?

Previously Booked

1st Time Booking

Address

City

Postal Code

Booking Contact Name

Email *

Phone #

Extension

Bill To

Same as Requesting Company

Send Invoice To...

Company Name

Attention

Address

City

Postal Code

Phone #

Extension

Email

Client/Passenger Information

Client Name

Passenger Cell #

Alternate Phone #

Policy #

File #

Claim #

Notes for Client/Passenger – include any alternate phone notes here

Interpreter?

Yes

No

Interpreter Name

Interpreter #

Trip 1 Details

Appointment Date

Appointment Time

AM/PM

AM

PM

Expected Length

Pick-Up (Building, Address, City)

Destination (Building, Address, City)

Physician

Destination Phone #

Ext

Return Trip

Yes

No

Special Instructions

Add More Trips?

No

+1 Trip

+2 Trips

+3 Trips

Client/Passenger being dropped off at a hotel?

No

Yes

CTS requires a copy of the hotel’s Credit Card Authorization Form that authorizes the booking credit card to also be used as the deposit credit card

• Reasoning behind this is that the client/passenger will be asked to provide a credit card or cash when trying to register into the hotel and they usually don’t have a credit card or cash and the hotel will not allow the client/passenger to register
• Usually a client/passenger is registering into the hotel after 5:00pm and businesses are closed and we have no one to contact to sort it out
• Please scan and send the form to reservation@ctsonline.ca
• If the client/passenger is being provided cash for the deposit, please let us know in special instructions (then the form is not required)

Trip 2 Details

Appointment Date

Appointment Time

AM/PM

AM

PM

Expected Length

Pick-Up (Building, Address, City)

Destination (Building, Address, City)

Physician

Destination Phone #

Ext

Return Trip

Yes

No

Special Instructions

Trip 3 Details

Appointment Date

Appointment Time

AM/PM

AM

PM

Expected Length

Pick-Up (Building, Address, City)

Destination (Building, Address, City)

Physician

Destination Phone #

Ext

Return Trip

Yes

No

Special Instructions

Trip 4 Details

Appointment Date

Appointment Time

AM/PM

AM

PM

Expected Length

Pick-Up (Building, Address, City)

Destination (Building, Address, City)

Physician

Destination Phone #

Ext

Return Trip

Yes

No

Special Instructions

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