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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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/Akan Afrikaans Albanian American Sign Language (ASL) Amharic Anuak Arabic Armenian Bahasa Bari Belarussian Bengali Bhutanese/Dzongkha Bosnian Bulgarian Burmese Cambodian Chin Chinese Chinese - Mandarin Croatian Czech Danish Dari Dinka Dutch Edo Eritrea Estonian Falam Chin Farsi Filipino Finnish French Fulani German Greek Guajarati Haitian Creole Hakha Hebrew Hindi Hungarian Ibo Icelandic Igbo Ilocano Ilonggo Indonesian Italian Japanese Kachin Karen Khmer KiKong Kikuyu Kinaray-a Kinyarwanda Kirundi Kiswahii Kono Korean Koulango Krio Kurdish Laotian Liberian Eng/Colloqua/Pigeon Eng Lingala Lituanian Malayalam Mandingo Mende Mizo Mon Nepali Norwegian Nuer Oromiffa/Afan Oromo Oromo Pashtu Patois (Jamacian) Polish Portuguese Portuguese Creole Pulaar Punjabi Romanian Russian Sango Serbian Serere Shiluk Sign Language Solvak Somali Spanish Sudanese Swahili Swedish Tagalog Taiwanese Tamil Tedim Telugu Temne Thai Tigrinya Tshiluba Turkish Twi Ukrainian Urdu Vietnamese Visaya Waray-Waray Wolof Yoruba Zo/Zomi Other 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