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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
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 Center Location
Med Center Clinic/Hotels (LOCAL only) *
Baylor-St_Lukes Liver/Kidney, 6620 Main
Baylor-St.Lukes Transplant, 6720 Bertner
DeBakey VA Center, 2002 Holcombe Blvd
MD Anderson WEST – 13900 Katy Fwy 77079
MDA Main lobby – 1515 Holcombe
MDA Mays Clinic, Entrance #7
MDA Proton, 1840 Old Spanish Trail
MDA The Woodlands, 100 Fellowship Dr. 77384
MEM-Hermann Advanced Cardio, 6400 Fannin
MEM-Hermann Transplant, Jones Pavilion, 6411 Fannin
Mem-Hermann, 920 Medical Plaza Dr, 77380
Methodist Cancer Clinic, 1130 Earle
Methodist OPC – 6565 Fannin
Smith Clinic, 2525 Holly Hall.
Texas Oncology – 501 W. Medical Center Blvd, Webster 77598
TX Oncology, 501 W. Medical Cent Blvd, Webster 77598
UT Professional, 6655 Travis St.
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.
