Medical Courier Pick Up Request

Medical Courier Pick Up Request
Request medical courier services for specimens, blood, and small medical supplies. Complete this form to schedule pickup. Final charges are based on distance and service level.
Facility Contact Name
Contact First NameContact last Name
Facility Email Address
example@example.com
Facility Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Shipment Details: Please describe the items being transported (e.g., specimen type, blood products, or medical supplies).
Preferred Pickup Date & Time
Pick Up Location (STAT and after-hours requests may incur additional charges)
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Delivery Location (STAT and after-hours requests may incur additional charges)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Special Instructions or Notes (optional)

Medical Courier Service (Mon-Fri) - Booking Request

Initial scheduling request for medical courier services. Final charges are based on distance and service type.

Free

STAT/Rush Delivery - Booking Request

STAT request fee applied to urgent, time-sensitive services requiring immediate response and priority handling.

$55.00

Weekend - Booking Request

Additional fee applied to services performed on Saturdays and Sunday(on call only)

$50.00

After Hour - Booking Request

Additional fee applied to services performed before 9:00 AM or after 6:00 PM due to extended operating hours.

$45.00

Holidays - Booking Request

Applied to deliveries performed on federal or state-recognized holidays. Covers limited availability and holiday operations.

$100.00

Total

Service & Payment Terms Agreement
Payment is due within 48 hours of service completion. Late payments incur a $25 fee for every additional 24 hours. Fees for STAT, after-hours, weekend, and holiday services apply as selected. By submitting this form, you agree to these terms.
Signature
Should be Empty:

Service & Payment Terms Agreement