ReEnvision Interpreter Request Form To place a request for either in person interpreting or to Pre-schedule a virtual interpreter, please complete the form below. Note, this form is NOT for on-demand video and audio/telephonic interpreting. Please enable JavaScript in your browser to complete this form.Customer (Parent Account) *Please Slect ReEnvisionMD, LLCReEnvisionMD, Richmond, LLCReEnvisionMD FL, LLCInternal Medicine Consultants IncSub Account (Bill To) *Please Select Arl_N Fillmore StWin_Berryville AveRckvll_Maryland AveIMC_Weight LosWin_W Jubal Early DrSub Account (Bill To) *Please Select Rich_W Broad StHenrco_Gayton RdRich_Midlothian TpkeWeight Loss_RichmondFred_Plank RdSub Account (Bill To) *Please SelectFM_GCTC_RetailFM_GCTC_LAFitLHigh+5th st.FM_ColonialLB_Hickopochee AveIMCFL_Weight LossSub Account (Bill To) *Please SelectIMC_Winchester OfficeIMC_Winchester UrologyPlease Check to Confirm Address *1220 N. Fillmore St Suite 150 Arlington, VA. 22201Please Check to Confirm Address *1117 Berryville Ave Winchester, VA. 22601Please Check to Confirm Address *26 Maryland Ave, Rockville, MD 20850Please Check to Confirm Address *172 Linden Drive Suite 100, Winchester, VA. 22601Please Check to Confirm Address *480 W Jubal Early Dr Suite 120 Winchester, VA 22601Please Check to Confirm Address *8904 W. Broad St Henrico VA 23294Please Check to Confirm Address *9782 Gayton Rd, Henrico, VA. 23238Please Check to Confirm Address *9101 Midlothian Tpke #200, Richmond, VA 23235Please Check to Confirm Address *2380 Plank Rd Fredericksburg, VA 22401Please Check to Confirm Address *9918 Gulf Coast Main St. Suite 100 Fort Myers, FL 33913Please Check to Confirm Address *10058 Gulf Center Dr Fort Myers, FL 33913Please Check to Confirm Address *2724 5th St W Suite A Lehigh Acres, FL. 33971Please Check to Confirm Address *3820 Colonial Blvd Suite 201 Fort Myers, FL. 33966Please Check to Confirm Address *870 W. Hickopochee Ave, Suite 100 LaBelle, FL. 33935Please Check to Confirm Address *148 Linden Dr, Suite 103 Winchester, VA. 22601What Type of Service do You Need? *Sign Language (ASL) InterpreterForeign Language (Spanish, French, etc) InterpreterWritten/Document TranslationReal Time Captioning (CART) Braille ServiceWould You Like the Interpreter In-Person at Your Location or Virtual (Virtual does not mean On-demand VRI) *In-PersonVirtual (tele-medicine, Zoom, Google Meets, etc)Is This a Medical Appointment? *Yes NoYour 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 *DateTimeEnd 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)CentralMountain Hawaii Arizona What Language Are You Requesting? *Do you Prefer a Gender for the Interpreter? *FemaleMaleNo PreferencePlease Briefly Describe the Appointment So We Know What to Expect *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, etcPlease 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 ServiceService 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? If This is a Recuring Appointment, Please enter additional Dates, Start/End Times. ONLY IF THE LOCATION IS THE SAMEOriginal 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 FeeeeNo, Please Complete as Quickly as Possible Without Rush FeeIf 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/MeetingNo. I Would Like SLUSA to Provide Me a Link and We Will Join the InterpreterPlease Enter the Link to Your Virtual Appointment *If you do not have the link ready at this time, please enter “I will provide the link closer to the appointment date” Submit
