To help us expedite your request for an interpreter, please fill out the following form as completely as possible. One of our DIS service representatives will be in touch with you shortly regarding your request. We normally respond within 30 minutes of receiving your request.

When submitting a request in the evening or on the weekend, please also call the office to ensure prompt attention to your request.

If same-day request please call the office at (844) 545-2946 to alert us to your request.

Click to download printable form here.

* indicates a required field

    Tell us about your appointment:
    Appointment Date:* (mm/dd/yy)
    		 Appointment Time:*
    Appointment Time Zone:*
    Deaf Consumer's First Name:*
    		Last Name:*
    Date of Birth (For Medical Only):
    Type of Appointment/Meeting:*
    		 Estimated Duration of Appt:*
    City:*
    		 State:*
    Zip:*
    VRI Connection Email:*
    		 Are you a first time client?*

    Contact Information Name & Phone:
    First Name:*
    		Last Name:*
    Title:*
    		 Organization:*
    Work Phone: (NO DASHES)*
    		 Fax Number: (NO DASHES)
    Email:*
    Are you a new client?:*

    Name & Phone of Person Making Request:

    Same as contact information above

    First Name:

    		Last Name:
    Phone: (NO DASHES)
    		Email:*

    Payment Information:
    Method of Payment:*
    Company Name:*
    Billing Address:
    City, State:
    		Zip:
    Purchase Order #:
    Accounting Contact Name:*
    		 Accounting Contact Phone: (NO DASHES)*
    Accounting Email: *

    Credit Card Billing Information:

    Please provide the following information if you wish to pay via credit card.
    *Convenience Fee of 3% will be added*
    Card Type:
    Name As It Appears On The Card:
    		 Card Number:
    Billing Address:
    City, State:
    		 Zip:
    Expiration Date: (mm/yy)

    Additional Information / Comments:
    I have read and agree to the cancellation policy below. *

    Information is submitted using secure connection

    • Last-minute cancellations and client “No-Show” will be billed at the 30-minute minimum or the actual time requested, whichever is greater.
    • Requests received with less than 48-hour notice will be billed at Time-and-a-half
    • Less than 48-hour cancellation & Client “No-Show” will be billed accordingly
    • Cancellation of multiple-day events requires 48 hr notification for 1st day plus an additional day (24 hours) for each day thereafter {i.e. a two-day event requires 72 hr notice, a three-day event requires 4 days (96hrs) notice, etc.}
    • Legal assignments – a minimum of 72-hour notice for scheduling and cancellations (requests w/less than 72-hrs – short notice rates)