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ACD VRI: Request VRI service

IMPORTANT!

Please be advised that all requests made through our internet service need to have a 48 hours notice. If you are requesting an assignment within the next two (2) business days (48 Hours), you must call our office to confirm receipt of the request. If your request is an emergency please call the office immediately or call our emergency number.

Office: (954) 431 6505

Emergency line (after 5:00PM):  (954) 347-5749

Please note: fields marked with * are required.

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VRI Request Form

Date(s) for appointment(mm/dd/yy)*	A value is required.Invalid format.A value is required.Please enter date as mm/dd/yy. mm/dd/yy
Start time*	A value is required.A value is required. Please remember to specify AM or PM
End time*	A value is required.A value is required. Please remember to specify AM or PM
Contact name*	A value is required.A value is required.
Contact phone*	A value is required.A value is required.
Client*	A value is required.A value is required.
Reason for appointment*	A value is required.A value is required.
Deaf Client name (full name)*	A value is required.A value is required.
Special notes
Name of Requester (your name)*	A value is required.A value is required.
Requester phone number*	A value is required.A value is required.
Requester email*	A value is required.Invalid email format.A value is required.Invalid email format.
Requester VP user ID*	A value is required.
Billing information
Company name*	A value is required.A value is required.
Company Address*	Street/apt	A value is required. A value is required.A value is required.
	City	A value is required. A value is required.A value is required.
	State	A value is required. A value is required.A value is required.
	Zip	A value is required. A value is required.A value is required.
Attention to*	A value is required.A value is required.

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acdvri.com - Accessible Communications for the Deaf- Video Relay Interpreting