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Address
4480 W Peoria Ave #103, Glendale, AZ 85302, USA
Telephone
623-267-1717
Email
rightridemed@gmail.com
Client Name
DOB
Weight
lbs
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Dialysis AMB
Dialysis WC
Dialysis STR
Doctor App AMB
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Doctor App STR
Facility to Facility AMB
Facility to Facility WC
Facility to Facility STR
Other AMB
Other WC
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Direct Admit AMB
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HOSP Discharge AMB
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Vehicle
Standard
Premium
SUV
WAV
Stretcher
No. of Passenger
1
2
3
4
Is Return Trip?
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