Interpreter Form Request

Sally J. Pimentel

Deaf & Hard of Hearing Center

1860 Boy Scout Dr. B208

Fort Myers, FL 33907

239-461-0334 voice

239-247-5821 video phone for deaf

239-461-0434 fax

www.dhhc.life

info@dhhc.life

Requester's Email:

Check here to receive email updates

PO# or client# or Cost Center Code (back of badge)

IMPORTANT - By submitting this request, you agree to the terms and procedures below: An email or fax will be sent to your office to confirm your request and give you an approximate cost of the assignment. If your organization needs to cancel this request, the Deaf & Hard of Hearing Center MUST BE NOTIFIED AS SOON AS POSSIBLE and no later than 24 hours prior to the assignment. If cancellation notification is not made within the 24 hour time frame, you will be billed for the total amount of your request. In the event that the Deaf & Hard of Hearing Center is unable to provide an interpreter, your office will be notified as soon as possible, no later than 1 business day before the scheduled assignment. *

Yes, I agree to the above terms and procedures.

City, Zip Code *

Sally J. Pimentel Deaf & Hard of Hearing Center

Sign Language Interpreter

Request Form

Thank you for choosing the Deaf and Hard of Hearing Center for your sign language interpreting needs. Please fill out the form below as completely as possible so we may match our qualified interpreter(s) for your specific assignment. A staff member will contact you by email or phone within 2 business days to discuss the details and billing. Please feel free to contact us at interpreting@dhhc.life or 239-461-0334 (ext. 2) with your questions. To request a Rate Sheet please email: interpreting@dhhc.life. For interpreting requests that will start within the next 24 hours, please call DHHC's emergency line at 239-461-0334 ext. 7 to contact the on-call interpreter. Thank you!

SCROLL UP for message after clicking submit button. Please call or email to insure we received your request. 239-461-0334 ext. 2 or email: interpreting@dhhc.life. If the RED SUBMIT button does not allow you to send, you have incomplete or inaccurate information. Please make corrections and click submit again.

I am requesting: (click below)

Requesting a Sign Language Interpreter

Dress Code *

Business Casual

Formal

Casual/jeans

Deaf Consumer Name *

Organization:

Billing Fax Number

City, State, Zip Code *

Assignment Rates: There are additional fees for after-hours, weekends, holidays and less than 24 hour notices, legal fees please inquire. All assignments have a minimum of 2 hours. *

Within 24 hours

Monday - Friday 9:00am - 5:00 pm

Weekend or Holiday

After-hours

Legal

End Date and Time of the assignment *

By clicking the submit button, you agree that you are authorized to request a sign language interpreter *

Yes, I am authorized to request a Sign Language Interpreter

Start Date and Time of the assignment *

Location of Assignment Address *

Requester's Phone Number *

Please describe the general situation. (ie. medical, meeting)

Requester's Name *

Billing confirmation/Agreement should be sent by: *

Billing Address *

Building or Room Number