Transportation Request Form So we may serve you --- please complete all information accurately. Don't forget to click SUBMIT! * Date * Last Name * First Name * Phone # Street Address City Zip Code Please select your county: Caroline County King George County Spotsylvania County Stafford County City of Fredericksburg Birth Date Are you a Medicaid recipient? Yes No Are you disabled? Yes No Appointment Date Appointment Time Destination - Street Address Destination - City Destination - Zip Code Pick Up Time Are you a wheelchair user? Yes No
