Schedule an Interpreter

Name*

First Last

Email*

Email Confirm Email

How did you hear about us?*

Company to be Billed:*

Department Requesting Services:*

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Name of Billing Contact:

First Last

Client Information

Name of Client:*

First Last

Case ID Number

PO Number

Date of Birth:*

Language:*

Client Description - Age:*

Adult
Child

Client Description - Gender:

Does the client have a preferred interpreter?:

Appointment

Date of Appointment:*

Appointment Location/Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Appointment Start Time:*

:

Appointment End Time:*

:

Provider Name; Dept; Telephone:*

Purpose:*

Client Phone (Optional):

Please provide a client phone number if you want our interpreter to place a reminder call to your client. Kindly note that this is just a courtesy call:

Please use the space below to inform us if the patient or customer in need of services is suspected of having, or known to have, any infectious diseases, including viruses:*

If not, please write "none" or "N/A."

Will this appointment take place Over the Phone, use MS Teams, Doxy.me, or any other remote meeting technology?:*

Yes
No

If you answered "yes" to the above question, then please provide the meeting URL, meeting ID, Password (if required), and phone number (if needed):

Would you like to use our online scheduling platform to submit future requests for interpreters:*

Yes
No
Please send us more information about the scheduling platform

Language Bank Interpreter to provide courtesy reminder call:

Yes

(Please note that this is ONLY courtesy reminder call and patient/client may still not show up to his/her appointment)

If a patient/client does not answer the phone and his answering machine/voice mail picks up a call or family member answers the phone, can interpreter provide/give full appointment info (date, time, location, name of hospital/clinic/department, providers name) on patient/client voice message or give this info to patient/client’s family member?:*

Yes
No

Agreement*

Yes, I agree

By submitting this request, you and your agency agree to the following LanguageBank terms: The requesting agency agrees to pay Language Bank a 2-hour minimum. Additional time will be assessed in 30 minutes increments, plus interpreter’s travel time and mileage expense. In case of cancelled or rescheduled appointments by the requesting agency with less than 24-hour notice prior to service start-time, or in the case of no-shows or late arrival beyond 30 minutes, the requesting agency is responsible for full payment.