Exacta Interpreting

Interpreting & Translating in over 100 languages
Transportation arranged 24 hours a day, 7 days a week
Chaperones for consultations, examinations and other medical procedures

CHAPERONE REQUEST

Please fillout the form below and submit.

If you require a service within 48 hours or need immediate assistance, please contact our office at 416-222-4622 or toll free number 1-866-639-2282.

Client Login:

COMPANY INFORMATION
Company Name: *
Contact Person: *
E-Mail: *
Telephone: *
Fax Number: *
Address: *
City: *
Province: *
Postal Code: *
ASSIGNMENT INFORMATION
Gender Preference of Chaperone:
Type of Assignment:
1st Date:
 Start Time:
 Duration:
Location
Location Telephone:
 Contact Name:
  
2nd Date:
 Start Time:
 Duration:
Location
Location Telephone:
 Contact Name:
  
3rd Date:
 Start Time:
 Duration:
Location
Location Telephone:
 Contact Name:
  
4th Date:
 Start Time:
 Duration:
Location
Location Telephone:
 Contact Name:
  
5th Date:
 Start time:
 Duration:
Location
Location Telephone:
 Contact Name:
  
Confirmation of this appointment by:
Confirm appointment with client:
CLIENT INFORMATION
Client Name:
Telephone Number:
Date of Loss (dd/mm/yy):
Claim Number:
BILLING INFORMATION     Same as referral information
Company:
Contact Person:
Address:
City:
Province:
Postal Code:
E-mail:
Comments:

 



© Copyright 2010 Exacta Interpreting Inc. All rights reserved