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Buckeye Transport Service
Non-Emergency Wheelchair Transportation

Reserve your Medical appointment or social event today!

Please fill in the form below to reserve your ambulette. All fields
marked with a (*) are required, Call us at 330-784-7388.

                               First Name*

                                Last Name*

                   Pick- Up Address*
              (please include city & zip)

                                 Medicaid #

        Destination Address:*
               (please include city & Zip)

              Appointment Date:*

           Appointment Time:*


                 Phone Number*

           Special Equipment
               Requirements
         (please check all that apply)


                        Comments:

                Ordering Facility
                                        (If Applicable)

                 E-Mail Address
                      (If Applicable)

Standard Wheelchair

Extra-Wide Wheelchair

Motorized Wheelchair

Oxygen Tank