You will be contacted within 24 hours upon receipt of your request to confirm or deny the transportation
FAIRFIELD COUNTY JOB & FAMILY SERVICES
CUSTOMER NET TRANSPORTATION REQUEST
Patient Name Social Security#
Phone Alternate Phone
Appointment Date Appointment Time
Name of Doctor
Address of Doctor
FCJFS will contact you within 24 hours upon receipt of your request to either confirm or deny.
If you have additional appointments, please use this form.
239 West Main Street, Lancaster, OH 43130