Book a Ride or Get in Touch

Ride Request Form

Schedule Your Transportation

Fill out the form below and we'll contact you promptly to confirm availability and provide pricing. All fields marked with * are required.

Full Name *

Phone Number *

Email Address (optional)

Pickup Address *

Destination / Drop-off Address *

Date Needed *

Preferred Pickup Time *

Type of Trip * Select trip type— Medical Appointment Dialysis Transportation Physical / Occupational Therapy Specialist Visit Hospital Discharge Pharmacy / Prescription Pickup Airport Transfer Work Commute Errands / Shopping Social Event / Church General Ride Other

Recurring Trips? No — one-time trip Yes — weekly Yes — twice a week Yes — three times a week (dialysis) Yes — other schedule

Additional Notes (optional)

I understand that Lifeline Ride Services is a private pay service and does not bill insurance or Medicaid. I agree to be contacted regarding my ride request.

Submit Ride Request —

We'll respond to your request within a few hours during business hours. For urgent needs, please call us directly.