Production Ambulance Services Request
Production Company
Show Name (+episode if applicable)
Your Name
First Name
Last Name
Position
Your Email
example@example.com
Your Phone Number
Please enter a valid phone number
Format: (000) 000-0000.
Would you like to send this quote to anyone else?
Yes (up to 5 emails)
Email
example@example.com
Email
example@example.com
Email
example@example.com
Email
example@example.com
Email
example@example.com
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Booking Details
Number of Days included in this Booking
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Day 1
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 1 Calc
Day 1 Calculated Hours
Day 1 Total Regular Hours
Day 1 Overtime (1.5x) Hours
Day 1 Overtime (2.0x) Hours
Day 1 Total Billed Hours
Site Contact 1
First and Last Name
Site Contact Number 1
Please enter a valid phone number
Format: (000) 000-0000.
PO 1
Amb 1 hrs
MTC 1 hrs
Medic 1 Reg
Medic 1 1.5
Medic 1 2.0
Day 2
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 2 Calc
Day 2 Calculated Hours
Day 2 Total Regular Hours
Day 2 Overtime (1.5x) Hours
Day 2 Overtime (2.0x) Hours
Day 2 Total Billed Hours
Amb 2 hrs
MTC 2 hrs
Medic 2 Reg
Medic 2 1.5
Medic 2 2.0
Site Contact 2
First and Last Name
Site Contact Number 2
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 2
Same PO as above?
Yes
Day 3
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 3 Calc
Day 3 Calculated Hours
Day 3 Total Regular Hours
Day 3 Overtime (1.5x) Hours
Day 3 Overtime (2.0x) Hours
Day 3 Total Billed Hours
Amb 3 hrs
MTC 3 hrs
Medic 3 Reg
Medic 3 1.5
Medic 3 2.0
Site Contact 3
First and Last Name
Site Contact Number 3
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 3
Same PO as above?
Yes
Day 4
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 4 Calc
Day 4 Calculated Hours
Day 4 Total Regular Hours
Day 4 Overtime (1.5x) Hours
Day 4 Overtime (2.0x) Hours
Day 4 Total Billed Hours
Amb 4 hrs
MTC 4 hrs
Medic 4 Reg
Medic 4 1.5
Medic 4 2.0
Site Contact 4
First and Last Name
Site Contact Number 4
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 4
Same PO as above?
Yes
Day 5
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 5 Calc
Day 5 Calculated Hours
Day 5 Total Regular Hours
Day 5 Overtime (1.5x) Hours
Day 5 Overtime (2.0x) Hours
Day 5 Total Billed Hours
Amb 5 hrs
MTC 5 hrs
Medic 5 Reg
Medic 5 1.5
Medic 5 2.0
Site Contact 5
First and Last Name
Site Contact Number 5
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 5
Same PO as above?
Yes
Day 6
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 6 Calc
Day 6 Calculated Hours
Day 6 Total Regular Hours
Day 6 Overtime (1.5x) Hours
Day 6 Overtime (2.0x) Hours
Day 6 Total Billed Hours
Amb 6 hrs
MTC 6 hrs
Medic 6 Reg
Medic 6 1.5
Medic 6 2.0
Site Contact 6
First and Last Name
Site Contact Number 6
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 6
Same PO as above?
Yes
Day 7
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 7 Calc
Day 7 Calculated Hours
Day 7 Total Regular Hours
Day 7 Overtime (1.5x) Hours
Day 7 Overtime (2.0x) Hours
Day 7 Total Billed Hours
Amb 7 hrs
MTC 7 hrs
Medic 7 Reg
Medic 7 1.5
Medic 7 2.0
Site Contact 7
First and Last Name
Site Contact Number 7
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 7
Same PO as above?
Yes
Day 8
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 8 Calc
Day 8 Calculated Hours
Day 8 Total Regular Hours
Day 8 Overtime (1.5x) Hours
Day 8 Overtime (2.0x) Hours
Day 8 Total Billed Hours
Amb 8 hrs
MTC 8 hrs
Medic 8 Reg
Medic 8 1.5
Medic 8 2.0
Site Contact 8
First and Last Name
Site Contact Number 8
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 8
Same PO as above?
Yes
Day 9
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 9 Calc
Day 9 Calculated Hours
Day 9 Total Regular Hours
Day 9 Overtime (1.5x) Hours
Day 9 Overtime (2.0x) Hours
Day 9 Total Billed Hours
Amb 9 hrs
MTC 9 hrs
Medic 9 Reg
Medic 9 1.5
Medic 9 2.0
Site Contact 9
First and Last Name
Site Contact Number 9
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 9
Same PO as above?
Yes
Day 10
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 10 Calc
Day 10 Calculated Hours
Day 10 Total Regular Hours
Day 10 Overtime (1.5x) Hours
Day 10 Overtime (2.0x) Hours
Day 10 Total Billed Hours
Amb 10 hrs
MTC 10 hrs
Medic 10 Rg
Medic 10 1.5
Medic 10 2.0
Site Contact 10
First and Last Name
Site Contact Number 10
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 10
Same PO as above?
Yes
Day 11
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 11 Calc
Day 11 Calculated Hours
Day 11 Total Regular Hours
Day 11 Overtime (1.5x) Hours
Day 11 Overtime (2.0x) Hours
Day 11 Total Billed Hours
Amb 11 hrs
MTC 11 hrs
Medic 11 Rg
Medic 11 1.5
Medic 11 2.0
Site Contact 11
First and Last Name
Site Contact Number 11
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 11
PO same as above?
Yes
Day 12
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 12 Calc
Day 12 Calculated Hours
Day 12 Total Regular Hours
Day 12 Overtime (1.5x) Hours
Day 12 Overtime (2.0x) Hours
Day 12 Total Billed Hours
Amb 12 hrs
MTC 12 hrs
Medic 12 Rg
Medic 12 1.5
Medic 12 2.0
Site Contact 12
First and Last Name
Site Contact Number 12
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 12
Same PO as above?
Yes
Day 13
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 13 Calc
Day 13 Calculated Hours
Day 13 Total Regular Hours
Day 13 Overtime (1.5x) Hours
Day 13 Overtime (2.0x) Hours
Day 13 Total Billed Hours
Amb 13hrs
MTC 13 hrs
Medic 13 Rg
Medic 13 1.5
Medic 13 2.0
Site Contact 13
First and Last Name
Site Contact Number 13
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 13
Same PO as above?
Yes
Day 14
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Service(s) Requested
Ambulance with 2 Medics
MTC with 1 Medic
Medic Only
Call Time (24-Hour Time)
Hours Minutes
Wrap Time (24-Hour Time)
Hours Minutes
Day 14 Calc
Day 14 Calculated Hours
Day 14 Total Regular Hours
Day 14 Overtime (1.5x) Hours
Day 14 Overtime (2.0x) Hours
Day 14 Total Billed Hours
Amb 14 hrs
MTC 14 hrs
Medic 14 Rg
Medic 14 1.5
Medic 14 2.0
Site Contact 14
First and Last Name
Site Contact Number 14
Please enter a valid phone number
Format: (000) 000-0000.
Same Site Contact as above?
Yes
PO 14
Same PO as above?
Yes
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Booking Summary
Ambulance
Total Ambulance Hours
Estimate for Ambulance Booking
MTC
Total MTC Hours
Estimate for MTC Booking
Medic
Total Regular Medic Hours
Total 1.5x OT Medic Hours
Total 2.0x OT Medic Hours
Total Medic Hours
Estimate for Medic Booking
Total Booking Estimate
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Site Contact Details
Have we provided medical services on this show before? (ie. is this a new show/season?)
Yes
No (you will be redirected to enter billing info upon submission of this form)
Documents for CEMS to sign (eg. vendor form, labour letter, service agreement, etc.)
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Additional Uploads
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