Schedule An Appointment

 

For your convenience, we are pleased to provide an online appointment system. The process is designed to increase accuracy and efficiency in scheduling your request. Upon completion, a Request For Reservation will be automatically sent to your Valdmed administrative team. A final reservation confirmation will be provided once we’ve confirmed that a service provider in your area is available to fill your request.

Online requests should be submitted by 3:00 pm the day before the appointment is needed. Requests for Monday appointments should be submitted by 3:00 pm Friday. Need an appointment today? Please call (678) 977-0148 or (678) 714-7281.

STEP 1: Type of Service Required
Transport: Ambulatory Wheelchair Stretcher | Language Service
Other (specify):
STEP 2: Client Information and Pick Up Location
*Required
*Client Name:
Street : Apt:
City: State: Zip: *Daytime Phone:
Cell Phone: Fax: *E-mail:
Best time to contact client: Morning Afternoon Evening Any Time
Preferred contact method: Daytime Phone Cell Phone Fax E-mail

STEP 3: Billing Information
Is the billing contact a private payer? Yes No
If the client is the billing contact, skip to STEP 4
If the client is not the billing contact please complete the information below:
Billing contact name: Street :
City: State: Zip: Daytime Phone:
Cell Phone: Fax: E-mail:

STEP 4: Private Pay Billing Information
Service Request Date:
Appointment Time:
Location Facility/Business Name (if applicable):
Street:
Apartment/Suite/Building:
City: State: Zip: Daytime Phone:
Please Indicate Any Special Requests or Instructions Below: