Fields below marked with an "*" indicates a required field and must be completed prior to form submission.

    By clicking onto the Send button below, I am hereby requesting to be granted user access to the AmbuServe Ambulance Portal to place ambulance service requests on behalf of the facility I have indicated herein. The information I have provided is true and correct to the best of my knowledge.

    Upon submission of this form, you will receive an auto-generated reply-email to confirm receipt of your request. The information will also include the information you have provided herein for your record. upon approval of your request, you will receive a second email indicating User approval with instructions on how to access the portal.

    Thank you for your interest in the AmbuServe Ambulance Portal.