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Mission Request – Local
LOCAL HOUSTON ride Request
Patient Email *
Next
LOCAL Ride - Key Mission details
*
We MUST know when you are travelling
In Bound
Out Bound
IN Bound is TO the Med Center. OUT Bound is going OUT from Med Center
PU Place *
Med Clinic
Other
Residence
Where are we picking you up?
Pick Up Time *
Use clock icon to set - time. When do you want to be picked up?
PATIENT INFO
Patient Name *
VET? *
Yes
No
Mark YES if Patient is a Military Vet
Patient Mobile# *
Please enter primary contact # for Patient
Preferred Comms method?
Call
Text
How can our Volunteer best contact you?
Patient Age *
PLEASE tell us the Patients Age
HGA WAIVER accepted *
Yes
No
Patient MUST agree YES to waive all liabilities. WAIVER can be viewed here https://groundangels.org/about-us/forms-downloads/liability-waiver/
Permission to use Mission IMAGES
Yes
No
TOTAL number of passengers in your group? *
1
2
3
4
Traveling companion NAME
LEAVE BLANK
Companion Mobile#
LEAVE BLANK
Please provide your Buddy mobile in case we cannot reach you
Relationship
(None)
Parent
Child
Spouse
Caregiver
Other
Emergency contact NAME
*
Required — who should we call if something happens to you during the ride?
Someone we can call in an emergency (not travelling with you).
Emergency contact PHONE
*
Patient HOME info
City *
Patient HOME City
HOME Zip *
Patient HOME Address
For HOUSTON residents only - NOT air travellers
Home near what Cross Streets?
What are the nearest major cross streets?
Pick Up Notes
Med Facility Location
Med Center Clinic/Hotels (LOCAL only) *
Baylor-St. Lukes Liver/Kidney, 6620 Main, 77030
Baylor-St. Lukes Transplant, 6720 Bertner, 77030
DeBakey VA Center, 2002 Holcombe Blvd, 77030
Houston Methodist Clinic, 1130 Earle, 77030
Houston Methodist OPC, 6565 Fannin, 77030
Houston Methodist WEST, 18300 – 18500 Katy Fwy, 77094
Houston Methodist Willowbrook, 18220 SH.249 77070
Houston Methodist Woodlands, 17189 I-45 North, The Woodlands, 77385
Kelsey Seybold – MAIN, 3003 W Holcombe Blvd, 77025
Kelsey Seybold – NORTH, 15655 Cypress Woods, 77014
MDA Main Lobby, 1515 Holcombe, 77030
MDA Mays Clinic, Entrance #7, 77030
MDA Northwest, 9922 Louetta Rd, 77070
MDA Proton, 1840 Old Spanish Trail, 77054
MDA The Woodlands, 100 Fellowship Dr. 77384
MDA WEST, 13900 Katy Fwy 77079
MEM-Hermann Advanced Cardio, 6400 Fannin, 77030
MEM-Hermann Transplant, Jones Pavilion, 6411 Fannin, 77030
MEM-Hermann, 920 Medical Plaza Dr, The Woodlands, 77380
Smith Clinic, 2525 Holly Hall. 77054
Texas Oncology, 501 W. Medical Center Blvd, Webster 77598
UT Professional, 6655 Travis St. 77030
If none of above - put special address below
PLEASE first CHECK if your location is in the drop down list. If NOT - please enter the Street address below.
Special Address
Zip
Med Center Notes
Add any helpful notes here if needed.
Specialist Doctor Name *
Please tell us your specialist Doctor name and Office phone number.
Doctor Office Phone *
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Note: If your request is not submitted/saved, please look up above for RED area and correct your entry.
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