Please fill out the form below and submit.

Patient/Principal Information

Please complete this information for the Patient or Primary Passenger who has a need for transportation. It is important that you provide a follow-up contact person for us to call to respond to your request. This may be a social worker, parent or yourself as the passenger.

Please note:

  • You will be asked to provide documentation of your family income. Examples include the first page of your most recent Federal tax return, social security, Medicaid or disabilty statement. Please have one electronic file with one or more of these documents ready to upload before you start this form.
  • If you have verification of your medical appointment (a letter from your physician, a printed appointment reminder, or a screen shot of your patient portal showing the appointment date), you can upload it at this time as well.

Items marked with * are required entries.

Primary Passenger Information

Use Full Legal Name as appears on your ID Card

This is the address where your gas card will be delivered. An adult must be available at this address to sign for the delivery. We cannot deliver to a PO Box.

*Gender  Male  Female 

Travel Information

Please complete as much detail as possible about the Primary Passengers Travel request.

Passenger is traveling FROM

Passenger is traveling TO

How many trips will be required for your treatment?*

Please explain your travel plans/needs in detail below.*

Escort Information

Use Full Legal Name as appears on your ID Card

Our program provides a round trip ticket for the patient traveling for treatment and one escort. If you are traveling with an escort please complete the following.

Gender:  Male  Female 

In order to further process your request for assistance we will need to know the gas station you prefer from the list of gas stations below. We can only provide gas cards from the list below.

Please choose your selections from the options below:

 76  Arco  BP  Chevron  Chevron Texaco  Circle K  Conoco  Exxon  Exxon Mobil  Gulf  Mobil  Phillips 66  Shell  Sinclair  Speedway  Sunoco  Texaco  WAWA 

Screening Information

As each trip is a gift from a donor, it is important for us to understand the financial need and reason for requesting assistance.
Please fill out a brief description in each box and answer the questions below to help us help you.

Patient's primary illness/condition (briefly)

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Financial Situation - Brief description of financial situation that warrants support

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Reason for travel - Brief description of passenger's illness, diagnosis, or reason for needing assistance

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Physician Information

Prior to coordinating a trip we must obtain a medical release from your personal physician. This physician must have seen you recently, be familiar with your current medical condition, and be willing to attest to your ability to travel safely.

Personal Physician Information (Your primary Physician)

Income & Appointment Verification

Please upload documentation verifying that you have a medical appointment at the facility specified above. Examples include a letter from you physician, a printed appointment reminder from the physician's office, or a screen shot of the appointment details from your online patient portal.*

Please upload documentation showing your household income. Examples include income tax forms, social security statements, or W2 forms.

Please choose the income bracket from the list below that best represents the patient's total, annual, household family income.*

Please the number of people living in your household.*

Please choose the ethnicity that best describes the patient.*

IMPORTANT: I authorize Angel Wheels to contact my physician through the information I have provided to obtain a medical clearance form showing proof of appointment:

 Yes  No