Schedule an Interpreter - Medical Please use this form to schedule for Medical requests. Requester Name * First & Last Requester Email * Company Name * Dept / Unit * Phone Number * Fax Number Claim Number / PO Identifying code for billing or case identification Assignment - On-Site Information On-Site Contact * Venue Building Name / Type Address * Address Address Include Suite / Apt # / Floor Include Suite / Apt # / Floor City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Date of Assignment * Make sure you select a VALID date in the future. Time * 121234567891011 : 000510152025303540455055 AMPM Duration * Minimum 2 hours Language to be interpreted * Abron/AkanAfrikaansAlbanianAmerican Sign Language (ASL)AmharicAnuakArabicArmenianBahasaBariBelarussianBengaliBhutanese/DzongkhaBosnianBulgarianBurmeseCambodianChinChineseChinese - MandarinCroatianCzechDanishDariDinkaDutchEdoEritreaEstonianFalam ChinFarsiFilipinoFinnishFrenchFulaniGermanGreekGuajaratiHaitian CreoleHakhaHebrewHindiHungarianIboIcelandicIgboIlocanoIlonggoIndonesianItalianJapaneseKachinKarenKhmerKiKongKikuyuKinaray-aKinyarwandaKirundiKiswahiiKonoKoreanKoulangoKrioKurdishLaotianLiberian Eng/Colloqua/Pigeon EngLingalaLituanianMalayalamMandingoMendeMizoMonNepaliNorwegianNuerOromiffa/Afan OromoOromoPashtuPatois (Jamacian)PolishPortuguesePortuguese CreolePulaarPunjabiRomanianRussianSangoSerbianSerereShilukSign LanguageSolvakSomaliSpanishSudaneseSwahiliSwedishTagalogTaiwaneseTamilTedimTeluguTemneThaiTigrinyaTshilubaTurkishTwiUkrainianUrduVietnameseVisayaWaray-WarayWolofYorubaZo/ZomiOther Language to be interpreted Select Other if you have a Special Needs Client (blind, limited reading skills, hard of hearing - not deaf). Please list need in popup box. Description of Services Required * Physical Therapy Labwork Counseling Dr. Appointment Follow-up Appointment Medication Management Surgery OtherOther If service is not listed, please select other and list service in box. Name of Patient with limited English proficiency: * Special Instructions Please include any notes about the client or future appointment needs that will help us fulfill your request. Cancellation Policy: FOREIGN LANGUAGE: Cancellations made within one business day of the assignment will be subject to our two hour minimum fee. SIGN LANGUAGE: Cancellations made within TWO business days of the assignment will be subject to our two hour minimum fee. policy agreement * I understand the Cancellation Policy stated above and by checking the box, I agree to these terms. Submit If you are human, leave this field blank.