Service Request Form

Use this form to place a request for an interpreter, document translation, CART, or if you’re new, please complete and we will reach out with information.

Are you a Current SLUSA Customer? *

• Yes my organization has a Service Agreement or Contract on File
• No, My organization does not have an Agreement and I need to get us set up

If You or Your Organization Have Never Used our Service and you Need To Setup a Pricing Agreement, Please Enter Your Name, Phone, and Email Address. We Will Contact You to Setup an Account. *

What Type of Service do You Need? *

• Sign Language (ASL) Interpreter
• Foreign Language (Spanish, French, etc) Interpreter
• Written/Document Translation
• Real Time Captioning (CART)
• Braille Service

Would You Like the Interpreter In-Person at Your Location or Virtual (Virtual does not mean On-demand VRI) *

• In-Person
• Virtual (tele-medicine, Zoom, Google Meets, etc)

Company/Organization Name *

The name of the company that will be paying for services

Location of Appointment (We Need This Even for Virtual Requests) *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Is This a Medical Appointment? *

• Yes
• No

Medical Department (If Applicable)

If this is a hospital or medical center, please state the department (ER, In-Patient Room, etc)

Is this a Radiology Appointment? *

• Yes
• No

Radiology *Select Radiology Unit Breast BiopsyCT ScanMammographyMRIUltrasoundX-RaySomething Else

Your name (First and Last Required) *

Phone Number Where You Can Be Reached *

It is important we are able to contact you by phone or email with any questions about your request.

Email *

Appointment Date / Start Time *

Date

Time

End Time (estimate if you don't know the exact end time) *

Time Zone *Please Select the Time Zone where the Appointment will Take PlacePacific (Los Angeles)Eastern (NYC)CentralMountainHawaiiArizona

What Language Are You Requesting? *

Do you Prefer a Gender for the Interpreter? *

• Female
• Male
• No Preference

Please Briefly Describe the Appointment So We Know What to Expect *

Do You Have any Prep Material For the Interpreter (Slides, PowerPoint, Scripts, Notes, Flyers, etc)? *

• Yes I do
• No I don’t

File Upload *

Click or drag a file to this area to upload.

Arrival Instructions for the Interpreter Such as Parking Expectations, Point of Contact, Where to Check-in, etc

Please provide any helpful information. Remember the Interpreter has likely never been to your location. Names, Phone numbers, and parking expectations are all appreciated.

Doctor/Provider Name *

Patient's Name *

The Name of the Person Requiring Interpreting Service

Patient's Date of Birth (if available)

Service Recipient Name (Name of the person requiring interpreting service) *

Special Language Request?

Does this person require a CDI, Tactile, Pro-Tactile, or other specialty type of interpreting?

Purchase Order (PO#) For Payment, if Applicable.

If your organization has funds set up in a Purchase Order, please enter that PO# here.

If This is a Recuring Appointment, Please enter additional Dates, Start/End Times. ONLY IF THE LOCATION IS THE SAME

Original Language of the Document *

Target Language of the Document *

What language do you want this document translated into? You can type in multiple languages if you require it translated into more than one language.

Briefly Describe the Document Needing Translation *

When Would You Like This Project Completed *

We will do our best to complete by your preferred date however, we will send you updates as we work.

Do You Want This Request Rushed?

• Yes Please Complete Within 24 Hours and Charge me Rush Feeee
• No, Please Complete as Quickly as Possible Without Rush Fee

If we complete the project within 24 hours without the rush request, you will NOT be charged a rush fee.

Please Upload The Document You Wish to be Translated

Click or drag files to this area to upload. You can upload up to 10 files.

Please Upload the file here. If you have any issues uploading, please email the file directly to DT@SLUSA.com

Will You Provide a Link for the Interpreter to Join? *

• Yes, I will Provide a Link to Our Appintment/Meeting
• No. I Would Like SLUSA to Provide Me a Link and We Will Join the Interpreter

Please Enter the Link to Your Virtual Appointment (No MS Teams Links) *

If you do not have the link ready at this time, please enter “I will provide the link closer to the appointment date”

Submit