Medical Interpreters – LangServ Translation Agency

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

Include Suite / Apt # / Floor

City

State/Province

Zip/Postal

Date of Assignment *

Make sure you select a VALID date in the future.

Time *

:

Duration *

Minimum 2 hours

Language to be interpreted * 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.