First Time Customer

Interpreter Request Form – First Time Customers

Thank you for using Accessible Languages, Inc. for your interpreting needs. You may submit an assignment request online by using the form below. Please submit your request at least 48 hours in advance of the time the service is needed. You will be contacted by the following business day for confirmation of the appointment. I you do not receive confirmation within that time period, please contact our office so we may take care of your needs @
ali@accessiblelanguages.com

Please provide the following information to request an interpreter. If you are requesting services before 8am or after 5pm Mon.-Fri. or on the weekend, please call or office.

ALL FIELDS ARE REQUIRED

 

Date of Assignment: (required)

Time of Assignment: (required)

Start Time: (required)

Hour Minutes

End Time: (required)

Hour Minutes

*You will be billed normal rate for time requested. Any overage will be billed at time and a half

Patient Name: (required)

Interpreter For: (required)

(Specify Language) : (required)

Assignment Location Address: (required)

Suite# :

City : (required)

State : (required)

Zip code :

Assignment Situation (ie. Dr. visit, test) (required)

Facility Contact Person: (required)

Phone# (required)

ext.

Facility Name : (required)

Requestor Name: (required)

Business Address: (required)

Suite #

City : (required)

State : (required)

Zip code :

Billing Contact Person: (required)

Billing Contact Phone#: (required)

Billing Contact Email: (required)

Business receiving Bill: (required)

Accounts Payable Contact Person: (required)

Billing Address: (required)

Suite#

City : (required)

State : (required)

Zip code : (required)

Billing Contact Phone#: (required)

Billing Contact Email: (required)

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