Northern Health Connections Travel Request

Travel Request

Online requests for travel must be submitted 48 hours prior to the travel date.

This is a request for travel not a booking, all bookings must be verified for qualification to use the service. To check if you qualify, please refer to the passenger information tab.

Within 24 hours an agent will review the request and during office hours will call back the number provided in the request to confirm the trip and secure payment.

All travel bookings must be completely booked and paid for by 14:00 the day prior to travel. If the travel date is in less than 48 hours, please call 1-888-647-4997.

Personal Information

* First Name:

* Last Name:

* Phone Number:

* Email:

* BC Care Card Number:

* Street:

Apt (Optional):

* City:

* Province:

* Postal Code:

* Emergency Contact Name:

* Emergency Contact Phone Number:

* Employee Y/N:

I am an employee of NHC [YES]
I am not an employee of NHC [NO]

Companion Information

* Companion Y/N:

I require a companion [YES]
I do not require a companion [NO]

Trip Information

* Departure Station:

* Arrival Station:

* Trip Type:

* Travel Date:

Open the calendar popup.

* Purpose of Travel:

* Doctor's Name:

* Appointment Date:

Open the calendar popup.

Assistance Required

Do you require assistance with any of the following:

Ambulatory
Wheel Chair
Scooter or Mobility Aid
Seizures
Asthma
Visual Impairment
Hearing Impairment
Allergies
Diabetes

Other Assistance Required: