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Request A Ride with ACL
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* Indicates required question
Name
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Medicaid #
Your answer
Address
*
Your answer
Phone number
*
Your answer
Drop off Address
*
Your answer
Date of appointment
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
Type of appointment
*
Doctor
Hospital
Dentist
Chemotherapy
Pharmacy
Urgent Care
Rehabilitation(physical therapy, occupational therapy and speech therapy
Dialysis
Other:
Facility/Doctor Name
*
Your answer
Facility/ DoctorNumber
*
Your answer
Type of Mobility
none
walker
cane
wheel chair
Clear selection
Event title
Your answer
Event date
MM
/
DD
/
YYYY
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