Patient Name: ____________________________
Date: ____________________________

1. Consent for Transportation

I, the undersigned, authorize Stretcher Mobility Care to provide non-emergency stretcher transportation services for the patient named above.

2. Acknowledgment of Non-Emergency Service

I understand that: This is NOT an emergency medical service
In case of emergency, I should call 911
Staff are not providing medical treatment beyond transport assistance

3. Patient Condition Disclosure

I confirm that: The patient is medically stable for non-emergency transport
All relevant medical or mobility conditions have been disclosed

4. Liability Waiver

I acknowledge and agree that:
Stretcher Mobility Care is not responsible for complications arising from pre-existing medical conditions
Transportation involves inherent risks, including movement and transfer

5. Personal Belongings

I understand that:
The company is not responsible for lost or damaged personal items

6. Payment Responsibility

I agree to: Pay all applicable fees for services provided
Follow agreed pricing terms

7. Authorization to Communicate

I authorize Stretcher Mobility Care to communicate with:
Family members
Caregivers
Healthcare facilities
for the purpose of coordinating transportation.

8. Signature

Patient / Representative Name: ____________________________
Signature: ____________________________
Date: ____________________________