ORION EMS Ambulance Request Form

Please Note: In a life threatening emergency you should always dial 911 for your local Police, Fire or Ambulance services.

In addition to calling our 24-hour dispatch center at 713-864-7900, you may also request and schedule a non-emergency ambulance transport by filling out the form below.

After receiving the ambulance request form below an operator from Orion EMS dispatch may contact you for additional information, regarding social security number and type of insurance plan or payment options. Please see our FAQ page for help with any additional questions you may have.

Requestor’s Name

First Name

Last Name

Requestor’s Email Address

Requestor’s Phone Number

(###)

###

####

Note | Message

Location | Date | Time

Pickup Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Closest Major Cross Street

Date Ambulance is Needed

MM

DD

YYYY

Pickup Time Requested

Destination Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Information

Patient’s Name

First Name

Last Name

Patient Gender

Male

Female

Patient’s Medical Condition

Reason for Ambulance Request

Patient’s Physician’s Name

First Name

Last Name

Patient’s Physician’s Phone

(###)

###

####

Insurance Type

Insurance Policy Number