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Medical Courier
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Courier Service Order Form
Online orders are available Monday – Friday, 8 AM to 5:30 PM
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*
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Payment Type
*
Credit Card
Client (After Hours)
Your Company Name
*
Your Name
*
Phone Number
*
Courier Pickup Information
Pick Up From
*
Street Address
*
Suite or Unit Number
Who do we see for pickup?
*
Courier Delivery Information
Deliver To
*
Street Address
*
Suite or Unit Number
Instructions for Courier
Is it OK to leave, if it's a residence?
*
Yes
No
Round Trip
*
No
Yes
Messenger Service Type
*
Regular – 4 hour local
Rush – 2 hour local
Non Stop - Based on Availability
Time frames are for local service within a 15 mile radius. Please call in requests for non stop service.
Email Address
*
Email you when delivered?
*
No
Yes
Instructions, including requested delivery time.
Date of delivery and Time package is ready
*
Hidden
Date of Delivery
Month
Day
Year
Hidden
Time package is ready
Hours
:
Minutes
AM
PM
AM/PM
Description of Package
*
Vehicle Requested
*
Car
Standard Pickup Truck (6 foot by 4 foot bed)
Van
Larger Truck
Do you have your credit card on file with us?
*
No
Yes