Transportation Assistance Request Form

We recognize that the road to managing epilepsy can be complex, with medical appointments and treatments demanding not only time but also reliable means of transportation. Our Transportation Assistance Program is here to bridge the gap, offering support to those who may find themselves facing hurdles in reaching their essential medical destinations.

Name *

First

Last

Are you over the age of 18? *

Phone Number *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Epilepsy Diagnosis *

Physician Name & Contact Information *

Are your seizures currently controlled? *

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Preferred mode of transportation (if any): *

Nearest Public Transportation Hub: *

Distance from Home to Nearest Treatment Center: *

Frequency of Medical Appointments: *

Household Income

Number of Dependants

Other Sources of Financial Support (if any):

Reason for Transportation Assistance: *

Specify if requesting one-time assistance or ongoing support: *

Additional Comments/Notes:

How did you hear about us? *

If you selected "referral" or "other," please specify.

Transportation Assistance Request Form

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