Book Now | Personal Assist Transit - Schedule Your Ride in Wichita, KS

Customer/Facility Name(Required)

Rider Name(Required)

First Last

Contact Phone Number(Required)

Email Address

Pickup Address

Street Address Address Line 2 City State ZIP / Postal Code

Date of Pick-up

Time of Pick-up

:

Appointment Time

:

Trip Type

Destination Address

Street Address Address Line 2 City State ZIP / Postal Code

Transportation Type

Does Client/Patient have own Wheelchair?

Escort?

Escort Name

First Last

Upon receipt of this form we will check the availability of date and time requested and contact you shortly to confirm and scheduled. The trip will not be scheduled without confirmation from a Personal Assist Transit Team Member.

Payment due on or before date of pickup unless you have been set up with a billing account.

Thanks for giving us a chance to assist you with your transportation need.

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