Ambulance Portal User Registration Form – AmbuServe Ambulance Service

Fields below marked with an "*" indicate 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.

Please leave this field empty.