Request Services | Milagro Medical Logistics

1

Organization Information

Organization / Facility Name *

Organization Type *

Industry / Specialty

Website (optional)

Federal Tax ID / EIN (optional)

Primary Pickup / Facility Address *

City *

State

ZIP Code *

Suite / Floor / Department

Do you have multiple pickup locations?

No — single location Yes — please describe below

Additional pickup location(s) (if applicable)

2

Primary Contact

First Name *

Last Name *

Title / Role *

Department

Email Address *

Direct Phone *

Extension (if applicable)

Best Time to Reach You

Will there be a separate billing contact?

No — same as above Yes

Billing Contact Name (if different)

Billing Contact Email

Billing Contact Phone

Purchase Order / Account # (if applicable)

3

Service Requirements

Delivery Priority Level *

⚡

STAT

Immediate / emergency dispatch, any hour

🕐

Urgent

Same-day or next available window

📅

Scheduled

Planned route or recurring delivery

Describe Materials in Detail *

Temperature Requirements

Approximate Package Size / Weight

Does the shipment require any special biohazard or UN-certified packaging?

Yes — biohazard / UN packaging No Unsure — please advise

Does this shipment fall under DOT hazardous materials regulations?

Yes No Unsure

4

Pickup & Delivery Details

Pickup Address *

Pickup Contact Name

Pickup Contact Phone

Preferred Pickup Date

Preferred Pickup Time

Delivery Address *

Delivery Recipient Name

Recipient Phone

Required Delivery Date

Required Delivery Time (if applicable)

Does delivery require a signature upon receipt? *

Yes — signature required No

Are there any special access requirements at pickup or delivery? (badges, call-ahead, loading dock, etc.)

5

Service Frequency & Contract

How often do you anticipate needing services? *

One-time delivery As-needed / on-call Weekly scheduled routes Daily routes Multiple times per day Custom schedule

Describe your ideal service schedule

Are you interested in a service contract or preferred partner agreement?

Yes, interested Open to discussing No — ad hoc only

Estimated monthly delivery volume

Do you have a current medical courier provider? If so, what are you looking to improve?

6

Compliance & Billing Preferences

Does your facility require proof of specific certifications from vendors? (Check all that apply)

HIPAA Business Associate Agreement (BAA) Certificate of Insurance (COI) OSHA Bloodborne Pathogen Certification DOT Hazmat Certification W-9 Form Vendor Application / Credentialing Background Check Documentation None required

Preferred billing method

Invoice / Net 30 Per-delivery payment Monthly contract billing To be discussed

Does your facility require a vendor onboarding process?

Yes No Unsure

Additional compliance, credentialing, or billing notes

7

Additional Information

How did you hear about Milagro Medical Logistics?

Is there anything else you'd like us to know about your service needs?

8

Authorization & Submission

By submitting this form, you confirm that you are an authorized representative of the organization listed above and that the information provided is accurate. Milagro Medical Logistics will use this information solely to evaluate and fulfill your service request. Submission does not constitute a binding agreement — a member of our team will follow up to confirm details, pricing, and terms.

I confirm I am an authorized representative of my organization and that all information provided is accurate. I understand that Milagro Medical Logistics will contact me to discuss this request and confirm service details before any delivery is scheduled. I am interested in receiving information about service contracts and preferred partner pricing. (Optional)

Request Medical Courier Services

Organization Information

Primary Contact

Service Requirements

Pickup & Delivery Details

Service Frequency & Contract

Compliance & Billing Preferences

Additional Information

Authorization & Submission

Response Timeframes

What Happens Next?

Prefer to Talk First?

Request Received!