Ambulance Portal User Registration Form – AmbuServe Ambulance Service

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

User Assigned Facility*

User First Name*

User Last Name*

User Email*

User Direct Phone Number* {Format: (XXX) XXX-XXXX}

User Phone Type*

User Position Title*

User Department*

User License/Certification Level*

Are you Authorized/Qualified to Sign an Ambulance Physician Certification Statement ("PCS") Form?*

Authorizing Facility Official's Name Approving You to Serve as A Portal User?*

Authorizing Facility Official's Position Title?*

Authorizing Facility Official's Email?*

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.